,NR 224 Exam 1 Fundamentals - Skills | Practice Questions & Answers
2026/2027 |
1.** A nursing student is performing a head-to-toe assessment on a 68-year-
old male admitted for heart failure. When auscultating the patient's lungs,
the student hears crackling sounds during inspiration that do not clear with
coughing. These sounds are most consistent with which finding?
A) Crackles caused by fluid accumulation in the alveoli and small airways
B) Wheezing caused by narrowed airways during expiration
C) Pleural friction rub caused by inflamed pleural surfaces
D) Stridor caused by upper airway obstruction
**Correct Answer:** A) Crackles caused by fluid accumulation in the alveoli
and small airways
**Rationale:** Crackles (formerly called rales) are discontinuous, popping
sounds heard during inspiration that do not clear with coughing. They
indicate fluid in the alveoli and small airways, commonly seen in heart failure
and pneumonia. Wheezing is expiratory and indicates narrowed airways;
pleural friction rub is a grating sound; stridor is a high-pitched upper airway
sound.
---
**2.** A nurse is conducting a patient-centered interview. Place the following
statements in the correct order.
1. "You say you've lost weight. Tell me how much weight you have lost in the
last month."
2. "My name is Todd. I'll be the nurse taking care of you today. I'm going to
ask you a series of questions to gather your health history."
,3. "I have no further questions. Thank you for your patience."
4. "Tell me what brought you to the hospital."
5. "So to summarize, you've lost about 6 pounds in the last month, and your
appetite has been poor—correct?"
A) 2, 4, 1, 5, 3
B) 4, 2, 1, 5, 3
C) 2, 1, 4, 5, 3
D) 4, 1, 2, 5, 3
**Correct Answer:** A) 2, 4, 1, 5, 3
**Rationale:** A patient-centered interview follows a logical sequence:
introduction and orientation (2), open-ended question to elicit the chief
concern (4), focused follow-up questions (1), summary to validate
understanding (5), and closure (3).
---
**3.** Which of the following are examples of data validation? (Select all that
apply.)
A) The nurse assesses the patient's heart rate and compares the value with
the last value entered in the medical record
B) The nurse asks the patient if he is having pain and then asks the patient
to rate the severity
C) The nurse observes a patient reading a teaching booklet and asks the
patient if he has questions about its content
D) The nurse obtains a blood pressure value that is abnormal and asks the
charge nurse to repeat the measurement
, E) The nurse asks the patient to describe a symptom by saying "go on"
**Correct Answer:** A, D
**Rationale:** Data validation involves verifying that assessment data are
accurate and complete. Comparing a new finding with previous documented
values (A) and having another clinician repeat an abnormal measurement (D)
are both validation strategies. Asking about pain severity (B) and probing for
more information (E) are data collection, not validation.
---
**4.** The nurse is assessing the character of a patient's migraine headache
and asks, "Do you feel nauseated when you have a headache?" The patient's
response is "yes." In this case, the finding of nausea is which of the
following?
A) An objective finding
B) A clinical inference
C) A validation
D) A concomitant symptom
**Correct Answer:** D) A concomitant symptom
**Rationale:** A concomitant symptom is a symptom that occurs alongside
the primary symptom. Nausea occurring with a migraine headache is a
concomitant symptom that helps characterize the patient's experience.
---
2026/2027 |
1.** A nursing student is performing a head-to-toe assessment on a 68-year-
old male admitted for heart failure. When auscultating the patient's lungs,
the student hears crackling sounds during inspiration that do not clear with
coughing. These sounds are most consistent with which finding?
A) Crackles caused by fluid accumulation in the alveoli and small airways
B) Wheezing caused by narrowed airways during expiration
C) Pleural friction rub caused by inflamed pleural surfaces
D) Stridor caused by upper airway obstruction
**Correct Answer:** A) Crackles caused by fluid accumulation in the alveoli
and small airways
**Rationale:** Crackles (formerly called rales) are discontinuous, popping
sounds heard during inspiration that do not clear with coughing. They
indicate fluid in the alveoli and small airways, commonly seen in heart failure
and pneumonia. Wheezing is expiratory and indicates narrowed airways;
pleural friction rub is a grating sound; stridor is a high-pitched upper airway
sound.
---
**2.** A nurse is conducting a patient-centered interview. Place the following
statements in the correct order.
1. "You say you've lost weight. Tell me how much weight you have lost in the
last month."
2. "My name is Todd. I'll be the nurse taking care of you today. I'm going to
ask you a series of questions to gather your health history."
,3. "I have no further questions. Thank you for your patience."
4. "Tell me what brought you to the hospital."
5. "So to summarize, you've lost about 6 pounds in the last month, and your
appetite has been poor—correct?"
A) 2, 4, 1, 5, 3
B) 4, 2, 1, 5, 3
C) 2, 1, 4, 5, 3
D) 4, 1, 2, 5, 3
**Correct Answer:** A) 2, 4, 1, 5, 3
**Rationale:** A patient-centered interview follows a logical sequence:
introduction and orientation (2), open-ended question to elicit the chief
concern (4), focused follow-up questions (1), summary to validate
understanding (5), and closure (3).
---
**3.** Which of the following are examples of data validation? (Select all that
apply.)
A) The nurse assesses the patient's heart rate and compares the value with
the last value entered in the medical record
B) The nurse asks the patient if he is having pain and then asks the patient
to rate the severity
C) The nurse observes a patient reading a teaching booklet and asks the
patient if he has questions about its content
D) The nurse obtains a blood pressure value that is abnormal and asks the
charge nurse to repeat the measurement
, E) The nurse asks the patient to describe a symptom by saying "go on"
**Correct Answer:** A, D
**Rationale:** Data validation involves verifying that assessment data are
accurate and complete. Comparing a new finding with previous documented
values (A) and having another clinician repeat an abnormal measurement (D)
are both validation strategies. Asking about pain severity (B) and probing for
more information (E) are data collection, not validation.
---
**4.** The nurse is assessing the character of a patient's migraine headache
and asks, "Do you feel nauseated when you have a headache?" The patient's
response is "yes." In this case, the finding of nausea is which of the
following?
A) An objective finding
B) A clinical inference
C) A validation
D) A concomitant symptom
**Correct Answer:** D) A concomitant symptom
**Rationale:** A concomitant symptom is a symptom that occurs alongside
the primary symptom. Nausea occurring with a migraine headache is a
concomitant symptom that helps characterize the patient's experience.
---
