NR302 Quiz 3 Las Vegas 2026 V2 - Chamberlain University
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Free NR302 Quiz 3 Las Vegas 2026 V2 - Chamberlain University Questions
What location can the nurse check skin turgor at?
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Fingernail
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Clavicle
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Earlobe
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Eyelashes
Explanation
Explanation:
Correct Answer: (B) Clavicle. The skin over the clavicle (or sternum) is a common site to assess skin turgor in adults, especially in older clients, since areas like the hands may have reduced elasticity due to aging, making the clavicular area more reliable for evaluating hydration status.
Why Other Options are Incorrect:
A. Fingernail. The fingernail is used to assess capillary refill, not skin turgor.
C. Earlobe. The earlobe is not a standard site used for assessing skin turgor.
D. Eyelashes. Eyelashes are not a site involved in skin turgor assessment at all.
Which respiratory assessment finding is normal?
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Absent tactile fremitus and hyperresonant percussion tones
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Increased tactile fremitus and dull percussion tones
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Adventitious sounds and limited chest expansion
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Vesicular breath sounds and symmetric tactile fremitus
Explanation
Explanation:
Correct Answer: (D) Vesicular breath sounds and symmetric tactile fremitus
Normal respiratory assessment findings include vesicular breath sounds — soft, low-pitched sounds heard over most lung fields — and symmetric tactile fremitus, meaning vibrations are felt equally on both sides of the chest during spoken words. These indicate healthy, unobstructed lung tissue.
Why Other Options are Incorrect:
A. Absent tactile fremitus and hyperresonant percussion tones — These findings suggest air trapping or pneumothorax, not a normal respiratory assessment.
B. Increased tactile fremitus and dull percussion tones — These findings are associated with consolidation such as pneumonia, where fluid or solid material replaces air in the lungs.
C. Adventitious sounds and limited chest expansion — Adventitious sounds such as crackles, wheezes, and rhonchi are abnormal breath sounds indicating underlying pathology such as asthma, pulmonary edema, or infection.
The nurse completes an assessment and notes a heart rate of 40. How should the nurse document this finding?
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Normal
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Bradycardia
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Tachycardia
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Bradypnea
Explanation
Explanation:
Correct Answer: (B) Bradycardia
A normal adult heart rate ranges from 60 to 100 beats per minute. A heart rate of 40 beats per minute is significantly below this range and is documented as bradycardia. This finding requires further assessment as it may indicate conduction abnormalities, medication effects, or increased vagal tone.
Why Other Options are Incorrect:
A. Normal — A heart rate of 40 is well below the normal range of 60 to 100 beats per minute and cannot be documented as normal.
C. Tachycardia — Tachycardia refers to a heart rate above 100 beats per minute, which is the opposite of what is observed in this client.
D. Bradypnea — Bradypnea refers to an abnormally slow respiratory rate, not a slow heart rate. These are two distinct assessment findings.
The nurse performs a percussion of the lung fields in an adult patient. The nurse notes a low-pitched, clear, hollow sound. How should the nurse document this finding?
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Dullness
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Stridor
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Resonance
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Crepitus
Explanation
Explanation:
Correct Answer: (C) Resonance
Resonance is the normal percussion sound heard over healthy, air-filled lung tissue. It is described as a low-pitched, clear, and hollow sound. This finding indicates that the underlying lung tissue contains the expected amount of air and is free of consolidation or fluid accumulation.
Why Other Options are Incorrect:
A. Dullness — Dullness is a soft, short, high-pitched percussion sound heard over solid or fluid-filled areas such as the liver, a consolidated lung, or pleural effusion. It is not a normal lung percussion finding.
B. Stridor — Stridor is a high-pitched, harsh breathing sound caused by upper airway obstruction. It is an auscultatory finding, not a percussion finding, and represents a medical emergency.
D. Crepitus — Crepitus is a crackling sensation felt on palpation of the skin when air is trapped in the subcutaneous tissue, or a crackling sound heard in joints. It is not a percussion finding related to lung assessment.
The nurse is caring for a patient with heart failure. Which assessment findings should the nurse recognize as consistent with this condition? Select all that apply.
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Increased blood pressure
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Dilated pupils
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Jugular vein distension
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Warm, dry skin
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Nausea and vomiting
Explanation
Explanation:
Correct Answer: (A) Increased blood pressure and (C) Jugular vein distension
Heart failure causes the heart to pump ineffectively, leading to fluid backup in the circulatory system. Jugular vein distension occurs due to increased venous pressure from fluid overload. Blood pressure may be elevated in early or compensated heart failure as the body activates compensatory mechanisms such as the renin-angiotensin-aldosterone system and sympathetic nervous system to maintain cardiac output.
Why Other Options are Incorrect:
B. Dilated pupils — Pupil changes are associated with neurological conditions or medication effects, not heart failure.
D. Warm, dry skin — Heart failure typically causes cool, clammy, and diaphoretic skin due to decreased cardiac output and compensatory peripheral vasoconstriction, not warm and dry skin.
E. Nausea and vomiting — While these can occasionally occur in heart failure due to hepatic congestion or medication side effects, they are not primary or defining assessment findings characteristic of heart failure.
During a health history interview, which question is considered open-ended?
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"Have you ever had surgery?"
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"Do you have chest pain?"
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"Is your pain worse at night?"
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"Can you describe how you have been feeling lately?"
Explanation
Explanation:
Correct Answer: (D) "Can you describe how you have been feeling lately?" This question invites the client to respond in their own words with a detailed, descriptive answer rather than a simple yes or no, making it an open-ended question that encourages the client to share more comprehensive information.
Why Other Options are Incorrect:
A. "Have you ever had surgery?" This is a closed-ended question that can be answered with a simple "yes" or "no."
B. "Do you have chest pain?" This is also a closed-ended question requiring only a "yes" or "no" response.
C. "Is your pain worse at night?" This is a closed-ended question that similarly prompts a "yes" or "no" answer.
Upon inspection, the nurse observes coughing, sputum production, barrel chest appearance, dyspnea, and weight loss. These findings are consistent with:
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Chronic Obstructive Pulmonary Disease
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Pneumothorax
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Pleural Effusion
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Atelectasis
Explanation
Explanation:
Correct Answer: (A) Chronic Obstructive Pulmonary Disease
The combination of chronic cough with sputum production, barrel chest from long-term air trapping, dyspnea, and weight loss are hallmark clinical features of COPD. The barrel chest develops due to chronic hyperinflation of the lungs, which increases the anteroposterior diameter of the thorax over time. Weight loss in COPD occurs due to increased work of breathing and systemic inflammation.
Why Other Options are Incorrect:
B. Pneumothorax — Presents acutely with sudden onset pleuritic chest pain, absent breath sounds on the affected side, tracheal deviation, and respiratory distress. It does not present with a barrel chest or chronic sputum production.
C. Pleural Effusion — Characterized by dullness on percussion, decreased breath sounds, and decreased tactile fremitus on the affected side. It does not produce barrel chest or chronic productive cough.
D. Atelectasis — Refers to the collapse of lung tissue and presents with decreased breath sounds, dullness on percussion, and reduced chest expansion on the affected side. It does not cause the chronic progressive findings described in this scenario.
Which finding would the nurse expect in a healthy nail assessment?
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Curved clubbed nails
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Thick yellow nails
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Smooth texture with pink nail beds
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Delayed capillary refill
Explanation
Explanation:
Correct Answer: (C) Smooth texture with pink nail beds. Healthy nails are expected to have a smooth texture and pink nail beds, reflecting normal tissue structure and adequate oxygenation and perfusion.
Why Other Options are Incorrect:
A. Curved clubbed nails. Clubbing is an abnormal finding associated with chronic hypoxia, not a healthy nail assessment.
B. Thick yellow nails. Thickened, yellow nails are often associated with fungal infection and are not a normal, healthy finding.
D. Delayed capillary refill. Delayed capillary refill indicates poor peripheral perfusion, which is an abnormal finding, not an expected healthy result.
A nurse is unable to palpate a radial pulse. Which pulse site should the nurse assess next in an emergency?
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Brachial
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Temporal
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Carotid
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Pedal
Explanation
Explanation:
Correct Answer: (C) Carotid. In an emergency when a peripheral pulse like the radial pulse cannot be palpated, the nurse should assess a large, central artery, the carotid pulse is the standard next site checked, as it is more reliable for detecting perfusion status during emergent or critical situations.
Why Other Options are Incorrect:
A. Brachial. While the brachial pulse can be assessed, it is not the standard next site in an emergency situation compared to the more centrally reliable carotid pulse.
B. Temporal. The temporal pulse is not a standard site used for emergency assessment of central perfusion status.
D. Pedal. The pedal pulse is a peripheral site and would be even less likely to be palpable than the radial pulse if the client is experiencing significantly compromised perfusion.
A client reports itching and redness after using a new lotion. Which question is most appropriate for the nurse to ask next?
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"Have you traveled recently?"
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"Do you have any medication allergies?"
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"When did you first notice the reaction?"
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"What did you eat today?"
Explanation
Explanation:
Correct Answer: (C) "When did you first notice the reaction?" Establishing the onset timing of the reaction in relation to the lotion use is the most directly relevant follow-up question, helping the nurse confirm a likely cause-and-effect relationship and gather essential information about the current problem.
Why Other Options are Incorrect:
A. "Have you traveled recently?" This question is not directly relevant to a localized skin reaction following new lotion use.
B. "Do you have any medication allergies?" While allergy history can be useful background information, it is not the most immediately relevant next question regarding this specific new topical reaction.
D. "What did you eat today?" Diet is not directly relevant to a topical skin reaction caused by a new lotion applied to the skin.
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