,NURS 120 Assessment 4 Introduction to Medical Surgical Nursing
Questions And Answers 2026/2027 West Coast University
Q1. Which finding is most concerning when assessing a patient with
respiratory distress?
A. Respiratory rate of 18/min
B. Oxygen saturation of 98% on room air
C. Inability to speak in complete sentences
D. Clear breath sounds bilaterally
Correct Answer: C
Rationale: Inability to speak in complete sentences indicates severe
respiratory distress and inadequate ventilatory reserve. It requires
immediate assessment and intervention.
Q2. Which assessment finding is characteristic of hypoxemia?
A. Cyanosis and restlessness
B. Increased appetite
C. Warm, flushed skin with normal mentation
D. Bradycardia without other findings
Correct Answer: A
Rationale: Hypoxemia can cause restlessness, anxiety, confusion, and
cyanosis, particularly when oxygenation is significantly impaired.
Q3. A nurse hears a high-pitched musical sound primarily during
expiration. How should this finding be documented?
A. Crackles
B. Rhonchi
C. Wheezes
D. Pleural friction rub
Correct Answer: C
Rationale: Wheezes are high-pitched musical sounds caused by narrowed
airways and are commonly associated with asthma and obstructive airway
disease.
**Q4. A nurse hears a low-pitched, coarse, snoring-like sound that partially
clears after the patient coughs. Which sound is this?
, A. Crackles
B. Rhonchi
C. Stridor
D. Pleural rub
Correct Answer: B
Rationale: Rhonchi are low-pitched sounds associated with secretions or
obstruction in larger airways and may improve after coughing.
**Q5. Which finding is most characteristic of crackles?
A. Musical sounds caused by narrowed bronchi
B. Low-pitched sounds that always disappear after coughing
C. Discontinuous popping sounds associated with fluid or reopening of small
airways
D. Harsh upper-airway sounds caused by laryngeal obstruction
Correct Answer: C
Rationale: Crackles are discontinuous sounds often associated with fluid in
the smaller airways or sudden opening of previously closed alveoli.
**Q6. A nurse hears a loud, high-pitched sound predominantly during
inspiration over the upper airway. Which finding should the nurse recognize?
A. Stridor
B. Rhonchi
C. Wheezing
D. Fine crackles
Correct Answer: A
Rationale: Stridor is a harsh, high-pitched upper-airway sound that can
indicate significant airway narrowing or obstruction and requires prompt
evaluation.
**Q7. A patient reports sharp chest pain that becomes worse when taking a
deep breath. What term best describes this symptom?
A. Visceral pain
B. Pleuritic chest pain
C. Referred abdominal pain
D. Musculoskeletal cramping
Correct Answer: B
Questions And Answers 2026/2027 West Coast University
Q1. Which finding is most concerning when assessing a patient with
respiratory distress?
A. Respiratory rate of 18/min
B. Oxygen saturation of 98% on room air
C. Inability to speak in complete sentences
D. Clear breath sounds bilaterally
Correct Answer: C
Rationale: Inability to speak in complete sentences indicates severe
respiratory distress and inadequate ventilatory reserve. It requires
immediate assessment and intervention.
Q2. Which assessment finding is characteristic of hypoxemia?
A. Cyanosis and restlessness
B. Increased appetite
C. Warm, flushed skin with normal mentation
D. Bradycardia without other findings
Correct Answer: A
Rationale: Hypoxemia can cause restlessness, anxiety, confusion, and
cyanosis, particularly when oxygenation is significantly impaired.
Q3. A nurse hears a high-pitched musical sound primarily during
expiration. How should this finding be documented?
A. Crackles
B. Rhonchi
C. Wheezes
D. Pleural friction rub
Correct Answer: C
Rationale: Wheezes are high-pitched musical sounds caused by narrowed
airways and are commonly associated with asthma and obstructive airway
disease.
**Q4. A nurse hears a low-pitched, coarse, snoring-like sound that partially
clears after the patient coughs. Which sound is this?
, A. Crackles
B. Rhonchi
C. Stridor
D. Pleural rub
Correct Answer: B
Rationale: Rhonchi are low-pitched sounds associated with secretions or
obstruction in larger airways and may improve after coughing.
**Q5. Which finding is most characteristic of crackles?
A. Musical sounds caused by narrowed bronchi
B. Low-pitched sounds that always disappear after coughing
C. Discontinuous popping sounds associated with fluid or reopening of small
airways
D. Harsh upper-airway sounds caused by laryngeal obstruction
Correct Answer: C
Rationale: Crackles are discontinuous sounds often associated with fluid in
the smaller airways or sudden opening of previously closed alveoli.
**Q6. A nurse hears a loud, high-pitched sound predominantly during
inspiration over the upper airway. Which finding should the nurse recognize?
A. Stridor
B. Rhonchi
C. Wheezing
D. Fine crackles
Correct Answer: A
Rationale: Stridor is a harsh, high-pitched upper-airway sound that can
indicate significant airway narrowing or obstruction and requires prompt
evaluation.
**Q7. A patient reports sharp chest pain that becomes worse when taking a
deep breath. What term best describes this symptom?
A. Visceral pain
B. Pleuritic chest pain
C. Referred abdominal pain
D. Musculoskeletal cramping
Correct Answer: B
