Fundamentals of Nursing Exam 3
As part of the cardiac assessment, to palpate the apical pulse, the nurse places the fingertips at which
location?
1. At the left midclavicular line at the fifth intercostal space
2. At the left midclavicular line at the third intercostal space
3. To the right of the left midclavicular line at the fifth intercostal space
4. To the right of the left midclavicular line at the third intercostal space - ANSWER:1
Rationale: The point of maximal impulse (PMI), where the apical pulse is palpated, is normally located in
the fourth or fifth intercostal space, at the left midclavicular line, Options 2, 3, and 4 are not descriptions
of the location for palpation of the apical pulse.
A client is admitted to the hospital with a diagnosis of right lower lobe pneumonia. The nurse auscultates
the affected lung area, expecting to note which type of breath sounds?
a. Absent
b. Vesicular
c. Bronchial
d. Bronchovesicular - ANSWER:c
Rationale: Bronchial sounds are normally heard over the trachea. The client with pneumonia will have
bronchial breath sounds over area(s) of consolidation because the consolidated tissue carries bronchial
sounds to the peripheral lung fields. The client may also have crackles in the affected area resulting from
fluid in the interstitium and alveoli. Absent breath sounds are not likely to occur unless a serious
complication of the pneumonia occurs. Vesicular sounds are normally heard over the lesser bronchi.
bronchioles, and lobes. Bronchovesicular sounds are normally heard over the main bronchi.
A school nurse is performing screening examinations for scoliosis. Which signs of scoliosis should the
nurse assess for? Select all that apply
1. Chest asymmetry
2. Equal waist angles
3. Unequal rib heights
4. Equal rib prominences
5. Equal shoulder heights
6. Lateral deviation and rotation of each vertebra - ANSWER:1, 3, 6
Rationale: Scoliosis is a lateral curvature of the spine. The signs include nonpainful lateral curvature of
the spine, a curve with one turn (C curve) or two compensating curves (S curve), lateral deviation and
,rotation of each vertebra, unequal shoulder heights, unequal waist angles, unequal rib prominences and
chest asymmetry, and unequal rib heights.
The nurse assesses cranial nerve XII in the client who sustained a stroke. To assess this cranial nerve,
which action would the nurse ask the client to perform?
1. Extend the arms
2. Extend the tongue
3. Turn the head toward the nurse's arm
4. Focus the eyes on an object held by the nurse - ANSWER:2
Rationale: Impairment of the cranial nerve XII can occur with a stroke. To assess the function of cranial
nerve XII (hypoglossal), the nurse should assess the client's ability to extend the tongue. Extending the
arms, turning the head toward the nurse's arm, and focusing the eyes on an object do not test the
function of cranial nerve XII.
The nurse is performing a cardiovascular assessment on a client with heart failure. Which item would the
nurse assess to obtain the best information about the client's left-sided heart function?
1. the status of breath sounds
2. The presence of peripheral edema
3. the presence of hepatojugular reflux
4. the presence of jugular vein distention - ANSWER:1
Rationale: The client with heart failure may present different symptoms depending on whether the right
or left side of the heart is failing. The assessment of breath sounds provides information about left-sided
heart function. Peripheral edema, hepatojugular reflux, and jugular vein distention are all signs of right-
sided heart function.
The nurse interprets that which observation is related to the dysfunction of cranial nerve III (oculomotor
nerve)?
1. Mild drowsiness
2. Unilateral ptosis
3. Diminished mental acuity
4. Less frequent spontaneous speech - ANSWER:2
Rationale: Ptosis of the eyelid is caused by pressure on and the dysfunction of cranial nerve III, the
oculomotor nerve. The remaining options identify signs of deteriorating level of consciousness.
The RN s observing a new nurse auscultate the breath sounds on a client with pneumonia. Which action
by the new nurse would lead the registered nurse to determine that there is a need for further teaching?
1. Asks the client to sit up straight
, 2. Uses the bell of the stethoscope
3. Places the stethoscope directly on the client's skin
4. Encourages the client to breathe slowly and deeply through the mouth - ANSWER:2
Rationale: The bell of the stethoscope is not used to auscultate breath sounds. The client ideally should
sit up and breathe slowly through the mouth. The diaphragm of the stethoscope, which is warmed
before use, is placed directly on the client's skin, not over a gown or clothing.
The nurse is performing an abdominal assessment on a client. Which finding should the nurse report to
the HCP?
1. Absence of a bruit
2. Concave, midline umbilicus
3. Pulsation between the umbilicus and pubis
4. Bowel sound frequency of 15 sounds per minute - ANSWER:3
Rationale: The presence of pulsation between the umbilicus and the pubis could indicate an abdominal
aortic aneurysm and should be reported to the primary HCP. Bruits are not normally present. The
umbilicus should be in the midline, with a concave appearance. Bowel sounds vary, according to the
timing of the last meal, and usually range in frequency from 5 to 35 per minute.
The nurse performing a physical assessment is preparing to auscultate the client's breath sounds. Where
would the nurse place the stethoscope to assess the bronchovesicular sounds?
1. Lower left lobe
2. Bottom of the trachea
3. Left upper lobe
4. Middle trachea - ANSWER:2
Rationale: Bronchovesicular breath sounds are heard over the main bronchi. Specifically, their normal
location is between the first and second intercostal spaces at the sternal border anteriorly and
posteriorly at T4 medial to the scapula. These sounds are moderate in pitch and medium in intensity, and
the durations of inspiration and expiration are equal. Bronchial breath sounds are heard over the
trachea. Vesicular breath sounds are heard over the lesser bronchi, the bronchioles, and the lobes.
The nurse performing a skin assessment on a client observes a skin lesion. The nurse would notify the
primary health care provider about which findings? Select all that apply.
1. Variegated color
2. Irregular borders
3. Uniform color of brown
4. Measures 2 to 3 mm in size
As part of the cardiac assessment, to palpate the apical pulse, the nurse places the fingertips at which
location?
1. At the left midclavicular line at the fifth intercostal space
2. At the left midclavicular line at the third intercostal space
3. To the right of the left midclavicular line at the fifth intercostal space
4. To the right of the left midclavicular line at the third intercostal space - ANSWER:1
Rationale: The point of maximal impulse (PMI), where the apical pulse is palpated, is normally located in
the fourth or fifth intercostal space, at the left midclavicular line, Options 2, 3, and 4 are not descriptions
of the location for palpation of the apical pulse.
A client is admitted to the hospital with a diagnosis of right lower lobe pneumonia. The nurse auscultates
the affected lung area, expecting to note which type of breath sounds?
a. Absent
b. Vesicular
c. Bronchial
d. Bronchovesicular - ANSWER:c
Rationale: Bronchial sounds are normally heard over the trachea. The client with pneumonia will have
bronchial breath sounds over area(s) of consolidation because the consolidated tissue carries bronchial
sounds to the peripheral lung fields. The client may also have crackles in the affected area resulting from
fluid in the interstitium and alveoli. Absent breath sounds are not likely to occur unless a serious
complication of the pneumonia occurs. Vesicular sounds are normally heard over the lesser bronchi.
bronchioles, and lobes. Bronchovesicular sounds are normally heard over the main bronchi.
A school nurse is performing screening examinations for scoliosis. Which signs of scoliosis should the
nurse assess for? Select all that apply
1. Chest asymmetry
2. Equal waist angles
3. Unequal rib heights
4. Equal rib prominences
5. Equal shoulder heights
6. Lateral deviation and rotation of each vertebra - ANSWER:1, 3, 6
Rationale: Scoliosis is a lateral curvature of the spine. The signs include nonpainful lateral curvature of
the spine, a curve with one turn (C curve) or two compensating curves (S curve), lateral deviation and
,rotation of each vertebra, unequal shoulder heights, unequal waist angles, unequal rib prominences and
chest asymmetry, and unequal rib heights.
The nurse assesses cranial nerve XII in the client who sustained a stroke. To assess this cranial nerve,
which action would the nurse ask the client to perform?
1. Extend the arms
2. Extend the tongue
3. Turn the head toward the nurse's arm
4. Focus the eyes on an object held by the nurse - ANSWER:2
Rationale: Impairment of the cranial nerve XII can occur with a stroke. To assess the function of cranial
nerve XII (hypoglossal), the nurse should assess the client's ability to extend the tongue. Extending the
arms, turning the head toward the nurse's arm, and focusing the eyes on an object do not test the
function of cranial nerve XII.
The nurse is performing a cardiovascular assessment on a client with heart failure. Which item would the
nurse assess to obtain the best information about the client's left-sided heart function?
1. the status of breath sounds
2. The presence of peripheral edema
3. the presence of hepatojugular reflux
4. the presence of jugular vein distention - ANSWER:1
Rationale: The client with heart failure may present different symptoms depending on whether the right
or left side of the heart is failing. The assessment of breath sounds provides information about left-sided
heart function. Peripheral edema, hepatojugular reflux, and jugular vein distention are all signs of right-
sided heart function.
The nurse interprets that which observation is related to the dysfunction of cranial nerve III (oculomotor
nerve)?
1. Mild drowsiness
2. Unilateral ptosis
3. Diminished mental acuity
4. Less frequent spontaneous speech - ANSWER:2
Rationale: Ptosis of the eyelid is caused by pressure on and the dysfunction of cranial nerve III, the
oculomotor nerve. The remaining options identify signs of deteriorating level of consciousness.
The RN s observing a new nurse auscultate the breath sounds on a client with pneumonia. Which action
by the new nurse would lead the registered nurse to determine that there is a need for further teaching?
1. Asks the client to sit up straight
, 2. Uses the bell of the stethoscope
3. Places the stethoscope directly on the client's skin
4. Encourages the client to breathe slowly and deeply through the mouth - ANSWER:2
Rationale: The bell of the stethoscope is not used to auscultate breath sounds. The client ideally should
sit up and breathe slowly through the mouth. The diaphragm of the stethoscope, which is warmed
before use, is placed directly on the client's skin, not over a gown or clothing.
The nurse is performing an abdominal assessment on a client. Which finding should the nurse report to
the HCP?
1. Absence of a bruit
2. Concave, midline umbilicus
3. Pulsation between the umbilicus and pubis
4. Bowel sound frequency of 15 sounds per minute - ANSWER:3
Rationale: The presence of pulsation between the umbilicus and the pubis could indicate an abdominal
aortic aneurysm and should be reported to the primary HCP. Bruits are not normally present. The
umbilicus should be in the midline, with a concave appearance. Bowel sounds vary, according to the
timing of the last meal, and usually range in frequency from 5 to 35 per minute.
The nurse performing a physical assessment is preparing to auscultate the client's breath sounds. Where
would the nurse place the stethoscope to assess the bronchovesicular sounds?
1. Lower left lobe
2. Bottom of the trachea
3. Left upper lobe
4. Middle trachea - ANSWER:2
Rationale: Bronchovesicular breath sounds are heard over the main bronchi. Specifically, their normal
location is between the first and second intercostal spaces at the sternal border anteriorly and
posteriorly at T4 medial to the scapula. These sounds are moderate in pitch and medium in intensity, and
the durations of inspiration and expiration are equal. Bronchial breath sounds are heard over the
trachea. Vesicular breath sounds are heard over the lesser bronchi, the bronchioles, and the lobes.
The nurse performing a skin assessment on a client observes a skin lesion. The nurse would notify the
primary health care provider about which findings? Select all that apply.
1. Variegated color
2. Irregular borders
3. Uniform color of brown
4. Measures 2 to 3 mm in size
