NSG 3160 Exam 2 V2 | NSG 3160 Health
Assessment | Actual Q&A with Rationale (NSG3160
Exam 2) | Galen
1. A nurse is performing a respiratory assessment on a patient with suspected pneumonia.
Which of the following findings would the nurse expect to identify during percussion and
auscultation of the affected area? (Select All That Apply)
A. Dullness to percussion
B. Hyperresonance to percussion
C. Increased tactile fremitus
D. Crackles (rales) upon auscultation
E. Vesicular breath sounds throughout
F. Bronchophony
Correct Answer: A,C,D,F
Explanation: Pneumonia causes consolidation in the lung tissue, which results in a dull
sound rather than resonance during percussion. Tactile fremitus is increased because
sound travels better through solid/liquid media than through air. The presence of fluid and
exudate leads to adventitious sounds like crackles and clearer transmission of spoken
words as seen in bronchophony.
,2. When assessing the carotid arteries, which action by the student nurse requires
intervention by the clinical instructor?
A. Palpating the carotid pulses one at a time.
B. Using the bell of the stethoscope to listen for turbulent blood flow.
C. Asking the patient to take a breath and hold it while auscultating for bruits.
D. Palpating both carotid pulses simultaneously to compare strength.
Correct Answer: D
Explanation: Simultaneous palpation of the carotid arteries can cause a reflex drop in
heart rate or blood pressure and may significantly reduce blood flow to the brain. It is
standard practice to assess each side individually to ensure patient safety and cerebral
perfusion. The instructor must intervene to prevent potential syncope or bradycardia.
3. A patient presents with a deep vein thrombosis (DVT) in the left lower extremity. Which of
the following are classic signs or symptoms the nurse would expect to document? (Select All
That Apply)
A. Unilateral edema
B. Coolness of the skin in the affected leg
C. Erythema (redness) of the calf
D. Localized warmth
E. Tenderness on palpation
, F. Weak or absent pedal pulses
Correct Answer: A,C,D,E
Explanation: DVT is characterized by inflammation and obstruction of venous return,
leading to unilateral swelling, warmth, and redness. Tenderness is common due to the
inflammatory process in the vein wall. Weak pulses and cool skin are typically associated
with arterial insufficiency rather than venous thrombosis.
4. During a cardiac assessment, the nurse hears a high-pitched, scratchy sound at the left
lower sternal border that persists when the patient holds their breath. How should the nurse
document this finding?
A. Pleural friction rub
B. S3 gallop
C. Grade II systolic murmur
D. Pericardial friction rub
Correct Answer: D
Explanation: A pericardial friction rub is caused by inflammation of the pericardial sac,
resulting in a high-pitched, scratchy sound. Unlike a pleural rub, it does not disappear when
the patient holds their breath because it is timed with the heartbeat. This finding is
indicative of pericarditis and should be reported to the provider.
Assessment | Actual Q&A with Rationale (NSG3160
Exam 2) | Galen
1. A nurse is performing a respiratory assessment on a patient with suspected pneumonia.
Which of the following findings would the nurse expect to identify during percussion and
auscultation of the affected area? (Select All That Apply)
A. Dullness to percussion
B. Hyperresonance to percussion
C. Increased tactile fremitus
D. Crackles (rales) upon auscultation
E. Vesicular breath sounds throughout
F. Bronchophony
Correct Answer: A,C,D,F
Explanation: Pneumonia causes consolidation in the lung tissue, which results in a dull
sound rather than resonance during percussion. Tactile fremitus is increased because
sound travels better through solid/liquid media than through air. The presence of fluid and
exudate leads to adventitious sounds like crackles and clearer transmission of spoken
words as seen in bronchophony.
,2. When assessing the carotid arteries, which action by the student nurse requires
intervention by the clinical instructor?
A. Palpating the carotid pulses one at a time.
B. Using the bell of the stethoscope to listen for turbulent blood flow.
C. Asking the patient to take a breath and hold it while auscultating for bruits.
D. Palpating both carotid pulses simultaneously to compare strength.
Correct Answer: D
Explanation: Simultaneous palpation of the carotid arteries can cause a reflex drop in
heart rate or blood pressure and may significantly reduce blood flow to the brain. It is
standard practice to assess each side individually to ensure patient safety and cerebral
perfusion. The instructor must intervene to prevent potential syncope or bradycardia.
3. A patient presents with a deep vein thrombosis (DVT) in the left lower extremity. Which of
the following are classic signs or symptoms the nurse would expect to document? (Select All
That Apply)
A. Unilateral edema
B. Coolness of the skin in the affected leg
C. Erythema (redness) of the calf
D. Localized warmth
E. Tenderness on palpation
, F. Weak or absent pedal pulses
Correct Answer: A,C,D,E
Explanation: DVT is characterized by inflammation and obstruction of venous return,
leading to unilateral swelling, warmth, and redness. Tenderness is common due to the
inflammatory process in the vein wall. Weak pulses and cool skin are typically associated
with arterial insufficiency rather than venous thrombosis.
4. During a cardiac assessment, the nurse hears a high-pitched, scratchy sound at the left
lower sternal border that persists when the patient holds their breath. How should the nurse
document this finding?
A. Pleural friction rub
B. S3 gallop
C. Grade II systolic murmur
D. Pericardial friction rub
Correct Answer: D
Explanation: A pericardial friction rub is caused by inflammation of the pericardial sac,
resulting in a high-pitched, scratchy sound. Unlike a pleural rub, it does not disappear when
the patient holds their breath because it is timed with the heartbeat. This finding is
indicative of pericarditis and should be reported to the provider.
