NUR 216 Exam 3, Real Test Questions & Answers With Rationales, 2024/25
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Course
NUR 216 Ex3
Institution
NUR 216 Ex3
NUR 216 Exam 3, Real Test Questions & Answers With Rationales-A nurse is assessing a client's cranial nerves. Which of the following client actions is an indication that cranial nerve 1 is intact?
A. The client can stick their tongue out
B. The client can smile symmetrically
C. The client can h...
NUR 216 Exam 3, Real Test Questions & Answers With Rationales
A nurse is assessing a client's cranial nerves. Which of the following client actions is an
indication that cranial nerve 1 is intact?
A. The client can stick their tongue out
B. The client can smile symmetrically
C. The client can hear whispered words
D. The client can identify a minty scent - D. The client can identify a minty scent
Rationale- Cranial nerve 1, the olfactory nerve, controls the sense of smell. To test this
nerve's function, the nurse should ask the client to identify a nonirritating aroma, such as
mint or coffee
A nurse is assessing a client's peripheral vascular status of the lower extremities. The
nurse should place their fingertips on the top of the client's foot, between the tendons of
the great toe and those of the toe next to it, in order to palpate which of the following
pulses?
A. Posterior tibial
B. Popliteal
C. Dorsalis Pedis
D. Femoral - C. Dorsalis Pedis
Rationale- To palpate the dorsalis pedis, the nurse should place their fingertips on the top
of the client's foot, between the extensor tendons of the great toe and those of the toe next
to it. The dorsalis pedis is the most common pulse tested in the lower extremities.
A nurse is palpating a tender area of a clients abdomen. The nurse slowly applies pressure
over the area with their fingertips, then quickly releases it. The client reports increased
pain on the release of pressure. Which of the findings should the nurse document?
A. Borborygmi
B. Rebound Tenderness
C. Tympany
D. Abdominal Guarding - B. Rebound Tenderness
Rationale- The nurse should document that the client is experiencing rebound tenderness,
which is an increase in pain when deep palpation over a tender area is released. Rebound
tenderness is in the right lower quadrant at McBurney's point (one-third the distance from
the anterior iliac crest to the umbilicus) is an indication of acute appendicitis.
A nurse is performing a cardiovascular assessment on a client which of the following
findings should the nurse expect?
A. A continuous sensation of vibration felt over the second and third left intercostal
spaces
,B. A high-pitched, scraping sound heard in the third intercostal space to the left of the
sternum
C. A brief thump felt near the fourth or fifth intercostal space near the left mid clavicular
line
D. A whooshing or swishing sound over the second intercostal space along the left
arsenal border - C. A brief thump felt near the fourth or fifth intercostal space near the
left mid clavicular line
Rationale- This is where you would inspect and palpate for the point of maximal impulse.
Also called an apical pulse station, it occurs as the Apex of the heart bumps against the
chest wall with each heartbeat. The apical impulse is not always visible but can be felt as
a brief thump. This is an expected finding and should be performed when you are
preparing to auscultate the apical pulse.
A nurse is performing a complete, head-to-toe physical examination for a client. Which
of the following physical assessment techniques should the nurse perform first?
A. Auscultation
B. Inspection
C. Percussion
D. Palpation - B. Inspection
Rationale- The first action the nurse should take using the nursing process is to assess the
client. The nurse should begin a complete physical examination by inspecting the client's
body systematically, observing for both expected and unexpected physical findings.
When assessing most body systems, the recommended order is inspection, palpation,
percussion, and auscultation.
A nurse is performing a physical examination of the spine for an older adult client. The
nurse should identify that which of the following findings is common with aging?
A. Lordosis
B. Kyphosis
C. Ankylosis
D. Scoliosis - B. Kyphosis
Rationale- kyphosis, a pronounced "hunchback" curvature of the spine, is an abnormal
angulation of the posterior curve of the thoracic spine, usually a result of osteoporosis. It
is most common in older adults and tends to increase with aging. This pronounced
convexity of the thoracic spine is also common in older clients who have had vertebral
fractures.
A nurse is performing a respiratory assessment on a client. The nurse auscultates a wet,
popping sound upon inspiration of the clients breathing. The nurse should identify this
observation as which of the following findings?
A. Crackles
B. Stridor
, C. Wheezes
D. Friction Rub - A. Crackles
Rationale- crackles, sometimes called rales, are wet, popping sounds created by air
moving through liquid or by collapsed alveoli snapping open on inspiration. They are
most common at the end of inspiration of breathing.
A nurse is performing an abdominal assessment on a client. Over which of the following
areas of the client's abdomen should the nurse attempt to auscultate active bowel sounds
first?
A. Right upper quadrant
B. Left upper quadrant
C. Right lower quadrant
D. Left lower quadrant - C. Right lower quadrant
Rationale-Evidence-based practice indicates that the first area the nurse should auscultate
for active bowel sounds is over the right lower quadrant of the client's abdomen. The
right lower quadrant is located to the right of the umbilicus and contains the ileocecal
valve. This is where the small intestine connects to the large intestine, and it is normally
very active with bowel sounds. For an average adult, the nurse should expect to hear 5 to
30 bowel sounds per minute.
A nurse is performing preparing to conduct a Romberg test on a client. The nurse should
explain to the client that the Romberg test is used to assess which of the following
characteristics?
A. Gait
B. Hearing
C. Vision
D. Balance - D. Balance
Rationale- The nurse should explain that the Romberg test is the most common test of
balance
A nurse is teaching a newly licensed nurse about using a stethoscope. Which of the
following instructions should the nurse include?
A. Insert the earpieces at a downward angle towards your nose
B. Use the diaphragm to listen to low-pitched sounds.
C. Drape the stethoscope over your neck when not in use.
D. Clean the stethoscope by immersing it in soapy water. - A. Insert the earpieces at a
downward angle towards your nose
Rationale-The nurse should insert the earpieces at a downward angle toward their nose
because this helps ensure that sounds are effectively transmitted to their eardrums.
Anterior Chest: Inspection - -Inspect the anterior chest for symmetry of chest movements
and visible pulsations
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