NURS 216/NURS216 HEALTH
ASSESSMENT ACTUAL EXAM
REVIEW WITH WELL
STRUCTURED Q&A
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Module 6-7
Reading
o ATI: 29
o Health Assess: 5-7
o Basic: 38
Exam 3 study guide and Lung sound attachment
The nurse is performing a respiratory assessment and detects a low pitch, soft sound. The
inspiratory phase is longer than expiration. The nurse interrupts this as:
o Vesicular sound
o Bronchovesicular
o Bronchial
o Tracheal
o Answer: Vesicular sound
When percussing the chest, what sound would the nurse expect to hear over the lungs?
o Resonance
o Hyperresonance
o Tympany
o Dullness
o Answer: resonance
The nurse auscultates an extra sound over the left lower lobe. The nurse should:
o Document finding
o Notify physician
o Ask client to cough
o Reassess in one hour
o Answer: Ask client to cough
Upon auscultation the nurse detects an extra gurgling, expiratory sound in the upper
airways. The nurse interrupts this as:
o Crackles
o Rhonchi
o Wheeze
o Friction Rub
o Answer: Rhonchi
Inspection of the chest includes assessing the anteriorposterior:lateral ratio. The normal
finding for an adult is:
o 1:1
o 1:2
o 1:3
o 1:4
o Answer: 1:2
The nurse is performing a cardiac assessment. Which site is best for palpating the PMI?
o Left Base
o Right Base
o LLSB
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