NSG 3850 Comprehensive Final Exam with
questions and verified answers and
rationale updated 2026
CORRECT ANSWERS ARE MARKED IN BOLD WITH
PART 1: HEALTH ASSESSMENT & FUNDAMENTALS (1-20)
1. A nurse auscultates the first heart sound (S1). This sound is produced by:
A. Closure of aortic and pulmonic valves
B. Closure of the mitral and tricuspid valves
C. Ventricular filling during diastole
D. Atrial contraction against a stiff ventricle
Rationale: S1 marks the beginning of systole and the closure of the AV valves.
2. Vesicular breath sounds are normally heard over:
A. The trachea
B. The upper sternum
C. The peripheral lung fields
D. The interscapular area
Rationale: Vesicular sounds are soft, low-pitched, and heard over most lung tissue.
3. A positive Murphy's sign is indicative of:
A. Appendicitis
B. Pancreatitis
C. Cholecystitis (gallbladder inflammation)
D. Peritonitis
Rationale: Pain with inspiration during RUQ palpation indicates gallbladder inflammation.
4. The nurse is assessing Cranial Nerve XI (Spinal Accessory). Which action is tested?
A. Stick out tongue
,B. Smile and frown
C. Shrug shoulders against resistance
D. Swallow and say "ah"
Rationale: CN XI innervates the trapezius and sternocleidomastoid muscles.
5. The normal range for intraocular pressure is:
A. 5-9 mmHg
B. 10-21 mmHg
C. 22-30 mmHg
D. 31-40 mmHg
Rationale: Pressures >21 mmHg increase the risk for glaucoma.
6. The Braden Scale is used to assess a patient's risk for:
A. Falls
B. Pressure injuries
C. Venous thromboembolism
D. Malnutrition
Rationale: It scores sensory perception, moisture, activity, mobility, nutrition, and friction/shear.
7. To assess for a pulse deficit, the nurse should:
A. Check radial pulse only
B. Auscultate apical pulse while palpating radial simultaneously
C. Compare right and left carotid pulses
D. Check brachial then radial
Rationale: A difference indicates inefficient cardiac contraction, as in atrial fibrillation.
8. The correct order for an abdominal assessment is:
A. Inspection, palpation, percussion, auscultation
B. Inspection, auscultation, percussion, palpation
C. Auscultation, inspection, percussion, palpation
D. Palpation, inspection, auscultation, percussion
, Rationale: Auscultate before percussion/palpation to avoid altering bowel sounds.
9. A Glasgow Coma Scale (GCS) score of 7 indicates:
A. Mild head injury
B. Moderate head injury
C. Full consciousness
D. Severe head injury / coma
Rationale: GCS 3-8 = severe, 9-12 = moderate, 13-15 = mild.
10. A patient with heat stroke typically presents with a core temperature of:
A. 99.5°F (37.5°C)
B. 100.4°F (38°C)
C. 102.2°F (39°C)
D. >104°F (>40°C)
Rationale: Heat stroke is defined as CNS dysfunction with a temperature >40°C.
11. The nurse notes pitting edema 4mm deep that lasts >1 minute. This is documented as:
A. 1+ edema
B. 2+ edema
C. 3+ edema
D. 4+ edema
Rationale: 3+ = 4mm depth, 6mm pitting, lasts 1-2 minutes.
12. Which finding is an early sign of hypoxia?
A. Cyanosis
B. Bradycardia
C. Restlessness and anxiety
D. Decreased respiratory rate
Rationale: Restlessness is an early sympathetic response before cyanosis or bradycardia.
13. The nurse is using the SBAR communication tool. 'B' stands for:
questions and verified answers and
rationale updated 2026
CORRECT ANSWERS ARE MARKED IN BOLD WITH
PART 1: HEALTH ASSESSMENT & FUNDAMENTALS (1-20)
1. A nurse auscultates the first heart sound (S1). This sound is produced by:
A. Closure of aortic and pulmonic valves
B. Closure of the mitral and tricuspid valves
C. Ventricular filling during diastole
D. Atrial contraction against a stiff ventricle
Rationale: S1 marks the beginning of systole and the closure of the AV valves.
2. Vesicular breath sounds are normally heard over:
A. The trachea
B. The upper sternum
C. The peripheral lung fields
D. The interscapular area
Rationale: Vesicular sounds are soft, low-pitched, and heard over most lung tissue.
3. A positive Murphy's sign is indicative of:
A. Appendicitis
B. Pancreatitis
C. Cholecystitis (gallbladder inflammation)
D. Peritonitis
Rationale: Pain with inspiration during RUQ palpation indicates gallbladder inflammation.
4. The nurse is assessing Cranial Nerve XI (Spinal Accessory). Which action is tested?
A. Stick out tongue
,B. Smile and frown
C. Shrug shoulders against resistance
D. Swallow and say "ah"
Rationale: CN XI innervates the trapezius and sternocleidomastoid muscles.
5. The normal range for intraocular pressure is:
A. 5-9 mmHg
B. 10-21 mmHg
C. 22-30 mmHg
D. 31-40 mmHg
Rationale: Pressures >21 mmHg increase the risk for glaucoma.
6. The Braden Scale is used to assess a patient's risk for:
A. Falls
B. Pressure injuries
C. Venous thromboembolism
D. Malnutrition
Rationale: It scores sensory perception, moisture, activity, mobility, nutrition, and friction/shear.
7. To assess for a pulse deficit, the nurse should:
A. Check radial pulse only
B. Auscultate apical pulse while palpating radial simultaneously
C. Compare right and left carotid pulses
D. Check brachial then radial
Rationale: A difference indicates inefficient cardiac contraction, as in atrial fibrillation.
8. The correct order for an abdominal assessment is:
A. Inspection, palpation, percussion, auscultation
B. Inspection, auscultation, percussion, palpation
C. Auscultation, inspection, percussion, palpation
D. Palpation, inspection, auscultation, percussion
, Rationale: Auscultate before percussion/palpation to avoid altering bowel sounds.
9. A Glasgow Coma Scale (GCS) score of 7 indicates:
A. Mild head injury
B. Moderate head injury
C. Full consciousness
D. Severe head injury / coma
Rationale: GCS 3-8 = severe, 9-12 = moderate, 13-15 = mild.
10. A patient with heat stroke typically presents with a core temperature of:
A. 99.5°F (37.5°C)
B. 100.4°F (38°C)
C. 102.2°F (39°C)
D. >104°F (>40°C)
Rationale: Heat stroke is defined as CNS dysfunction with a temperature >40°C.
11. The nurse notes pitting edema 4mm deep that lasts >1 minute. This is documented as:
A. 1+ edema
B. 2+ edema
C. 3+ edema
D. 4+ edema
Rationale: 3+ = 4mm depth, 6mm pitting, lasts 1-2 minutes.
12. Which finding is an early sign of hypoxia?
A. Cyanosis
B. Bradycardia
C. Restlessness and anxiety
D. Decreased respiratory rate
Rationale: Restlessness is an early sympathetic response before cyanosis or bradycardia.
13. The nurse is using the SBAR communication tool. 'B' stands for:
