NUR 101/NUR101 Exam 2 V1 | Health
Assessment Q&A with Rationale | Fortis
College
1. When performing a physical assessment, which technique should the nurse always perform
first for every system except the abdomen?
A. Palpation
B. Inspection
C. Percussion
D. Auscultation
Correct Answer: B
Expert Explanation: Inspection is the first step of the physical assessment process and
involves concentrated watching. It begins the moment you first meet the person and
develop a ‘general survey’. This technique provides a wealth of information regarding the
patient’s general health status before any physical contact is made.
2. The nurse is assessing a patient’s skin turgor. Which finding would be considered a normal
sign of adequate hydration?
A. Skin remains tented for 5 seconds
B. Skin shows a slow recoil of 3 seconds
C. Skin is dry and flaky upon release
,D. Skin snaps back immediately to its original position
Correct Answer: D
Expert Explanation: Skin turgor is an indicator of hydration status and skin elasticity.
When the skin is pinched and released, it should instantly return to its flat position. If the
skin remains tented or takes several seconds to return, it suggests dehydration or extreme
weight loss.
3. During a respiratory assessment, the nurse notes a ‘popping’ sound like Velcro being pulled
apart at the end of inspiration. How should this be documented?
A. Wheezes
B. Rhonchi
C. Crackles
D. Stridor
Correct Answer: C
Expert Explanation: Crackles (previously called rales) are adventitious lung sounds that
are discontinuous and resemble the sound of hair rubbing together or Velcro opening. They
are caused by the popping open of previously deflated airways or the movement of fluid.
These sounds are most commonly heard during the inspiratory phase of the respiratory
cycle.
4. Where is the best anatomical location for the nurse to auscultate the apical pulse?
A. Second intercostal space, right sternal border
, B. Fifth intercostal space, left midclavicular line
C. Fourth intercostal space, left sternal border
D. Second intercostal space, left sternal border
Correct Answer: B
Expert Explanation: The apical pulse, or point of maximal impulse (PMI), is located at the
5th intercostal space at the midclavicular line. This location allows the nurse to listen
directly over the mitral valve and the apex of the heart. This site provides the most accurate
assessment of the heart’s rate and rhythm.
5. A patient presents with a lesion that is flat, less than 1 cm in diameter, and has a different
color than the surrounding skin. This is described as a:
A. Papule
B. Nodule
C. Macule
D. Pustule
Correct Answer: C
Expert Explanation: A macule is a primary skin lesion characterized as being flat and
circumscribed, measuring less than 1 cm. Common examples include freckles, flat nevi, and
petechiae. Because it is not elevated, it cannot be felt during palpation.
Assessment Q&A with Rationale | Fortis
College
1. When performing a physical assessment, which technique should the nurse always perform
first for every system except the abdomen?
A. Palpation
B. Inspection
C. Percussion
D. Auscultation
Correct Answer: B
Expert Explanation: Inspection is the first step of the physical assessment process and
involves concentrated watching. It begins the moment you first meet the person and
develop a ‘general survey’. This technique provides a wealth of information regarding the
patient’s general health status before any physical contact is made.
2. The nurse is assessing a patient’s skin turgor. Which finding would be considered a normal
sign of adequate hydration?
A. Skin remains tented for 5 seconds
B. Skin shows a slow recoil of 3 seconds
C. Skin is dry and flaky upon release
,D. Skin snaps back immediately to its original position
Correct Answer: D
Expert Explanation: Skin turgor is an indicator of hydration status and skin elasticity.
When the skin is pinched and released, it should instantly return to its flat position. If the
skin remains tented or takes several seconds to return, it suggests dehydration or extreme
weight loss.
3. During a respiratory assessment, the nurse notes a ‘popping’ sound like Velcro being pulled
apart at the end of inspiration. How should this be documented?
A. Wheezes
B. Rhonchi
C. Crackles
D. Stridor
Correct Answer: C
Expert Explanation: Crackles (previously called rales) are adventitious lung sounds that
are discontinuous and resemble the sound of hair rubbing together or Velcro opening. They
are caused by the popping open of previously deflated airways or the movement of fluid.
These sounds are most commonly heard during the inspiratory phase of the respiratory
cycle.
4. Where is the best anatomical location for the nurse to auscultate the apical pulse?
A. Second intercostal space, right sternal border
, B. Fifth intercostal space, left midclavicular line
C. Fourth intercostal space, left sternal border
D. Second intercostal space, left sternal border
Correct Answer: B
Expert Explanation: The apical pulse, or point of maximal impulse (PMI), is located at the
5th intercostal space at the midclavicular line. This location allows the nurse to listen
directly over the mitral valve and the apex of the heart. This site provides the most accurate
assessment of the heart’s rate and rhythm.
5. A patient presents with a lesion that is flat, less than 1 cm in diameter, and has a different
color than the surrounding skin. This is described as a:
A. Papule
B. Nodule
C. Macule
D. Pustule
Correct Answer: C
Expert Explanation: A macule is a primary skin lesion characterized as being flat and
circumscribed, measuring less than 1 cm. Common examples include freckles, flat nevi, and
petechiae. Because it is not elevated, it cannot be felt during palpation.
