NUR-201: FINAL QUESTIONS WITH COMPLETE
SOLUTIONS
⭐ Cardiovascular
Heart valves at which rib spaces Correct Answers Aortic: 2nd
ICS RSB
Pulmonic: 2nd ICS LSB
Erb's: 3rd ICS LSB
Tricuspid: 4th ICS LSB
Mitral: 5th ICS MCL
⭐ Vital Signs
Normal Values (Adults) Correct Answers Temp: 36.5°C to
37°C (97.7°F to 98.6°F)
Pulse: 60-100 bpm
Resp: 12-20/min
BP: < 120/80
O₂ Sat: ≥ 95%
Pain: 0-10 scale
A — Airway = Correct Answers (Obstruction / Clearance
Problems)
Asthma attack, COPD with mucus plugging, pneumonia with
secretions, excacerbation, asthma attack, SOB
A — Airway Correct Answers Priority: Ensure the airway is
open and not obstructed by secretions.
,What you assess:
Is the airway patent?
Ability to clear secretions (cough strength, sputum production)
Presence of:
Gurgling
Stridor
Drooling
Ineffective cough
Use of accessory muscles (may signal compromised airway
clearance)
Why it matters:
Pneumonia increases mucus and inflammation.A blocked airway
= no oxygen can enter the lungs, even if the patient is breathing.
Immediate nursing priorities:
Position in high Fowler's to open the airway
Encourage coughing and deep breathing
Suction if patient cannot clear secretions
Maintain a clear oral airway if needed
A client present to the ED with a muscular cylindrical organ
protruding from the vaginal vault - what is this most likely?
Correct Answers Uterine prolapse
Abdominal Signs
1. Murphy Sign Correct Answers Palpate right upper quadrant
at the costal margin, ask patient to inhale deeply
Positive Finding: Sudden pain and inspiratory arrest
,Cholecystitis (inflamed gallbladder)
Abdominal Signs
2. Blumberg Sign (Rebound Tenderness) Correct Answers
Press deeply into abdomen, then release quickly
TESTS FOR: Appendicular-like pain
Positive Finding: Pain upon release
Peritoneal irritation (e.g., appendicitis, peritonitis)
Abdominal Signs
3. Psoas Sign Correct Answers Patient lies supine, lift right leg
straight against resistance OR flex hip while lying on left side
Pain in right lower quadrant
Appendicitis (retrocecal appendix)
Abdominal Signs
4. Obturator Sign Correct Answers Flex patient's right hip and
knee, rotate internally at hip
Pain in RLQ
Appendicitis (pelvic appendix)
, Abdominal Signs
5. Rovsing Sign Correct Answers Press left lower quadrant
Pain in right lower quadrant
Appendicitis
Abdominal Signs
6. Heel Tap / Markle Sign Correct Answers Patient stands on
toes, then drops heels sharply, or tap heels supine
Pain in RLQ
Peritoneal irritation
Abdominal Signs
7. Grey-Turner Sign Correct Answers Ecchymosis of flanks
Bruising
Retroperitoneal hemorrhage
Abdominal Signs
8. Cullen Sign Correct Answers Ecchymosis of periumbilical
area
SOLUTIONS
⭐ Cardiovascular
Heart valves at which rib spaces Correct Answers Aortic: 2nd
ICS RSB
Pulmonic: 2nd ICS LSB
Erb's: 3rd ICS LSB
Tricuspid: 4th ICS LSB
Mitral: 5th ICS MCL
⭐ Vital Signs
Normal Values (Adults) Correct Answers Temp: 36.5°C to
37°C (97.7°F to 98.6°F)
Pulse: 60-100 bpm
Resp: 12-20/min
BP: < 120/80
O₂ Sat: ≥ 95%
Pain: 0-10 scale
A — Airway = Correct Answers (Obstruction / Clearance
Problems)
Asthma attack, COPD with mucus plugging, pneumonia with
secretions, excacerbation, asthma attack, SOB
A — Airway Correct Answers Priority: Ensure the airway is
open and not obstructed by secretions.
,What you assess:
Is the airway patent?
Ability to clear secretions (cough strength, sputum production)
Presence of:
Gurgling
Stridor
Drooling
Ineffective cough
Use of accessory muscles (may signal compromised airway
clearance)
Why it matters:
Pneumonia increases mucus and inflammation.A blocked airway
= no oxygen can enter the lungs, even if the patient is breathing.
Immediate nursing priorities:
Position in high Fowler's to open the airway
Encourage coughing and deep breathing
Suction if patient cannot clear secretions
Maintain a clear oral airway if needed
A client present to the ED with a muscular cylindrical organ
protruding from the vaginal vault - what is this most likely?
Correct Answers Uterine prolapse
Abdominal Signs
1. Murphy Sign Correct Answers Palpate right upper quadrant
at the costal margin, ask patient to inhale deeply
Positive Finding: Sudden pain and inspiratory arrest
,Cholecystitis (inflamed gallbladder)
Abdominal Signs
2. Blumberg Sign (Rebound Tenderness) Correct Answers
Press deeply into abdomen, then release quickly
TESTS FOR: Appendicular-like pain
Positive Finding: Pain upon release
Peritoneal irritation (e.g., appendicitis, peritonitis)
Abdominal Signs
3. Psoas Sign Correct Answers Patient lies supine, lift right leg
straight against resistance OR flex hip while lying on left side
Pain in right lower quadrant
Appendicitis (retrocecal appendix)
Abdominal Signs
4. Obturator Sign Correct Answers Flex patient's right hip and
knee, rotate internally at hip
Pain in RLQ
Appendicitis (pelvic appendix)
, Abdominal Signs
5. Rovsing Sign Correct Answers Press left lower quadrant
Pain in right lower quadrant
Appendicitis
Abdominal Signs
6. Heel Tap / Markle Sign Correct Answers Patient stands on
toes, then drops heels sharply, or tap heels supine
Pain in RLQ
Peritoneal irritation
Abdominal Signs
7. Grey-Turner Sign Correct Answers Ecchymosis of flanks
Bruising
Retroperitoneal hemorrhage
Abdominal Signs
8. Cullen Sign Correct Answers Ecchymosis of periumbilical
area
