NUR 101/NUR101 Exam 3 V1 | Health
Assessment Q&A with Rationale | Fortis
College
1. A nurse is performing an abdominal assessment on a client. What is the correct sequence
of assessment techniques for this specific body system?
A. Inspection, Palpation, Percussion, Auscultation
B. Percussion, Palpation, Inspection, Auscultation
C. Auscultation, Inspection, Palpation, Percussion
D. Inspection, Auscultation, Percussion, Palpation
Correct Answer: D
Expert Explanation: In abdominal assessment, auscultation is performed before
percussion and palpation to prevent the stimulation of bowel sounds that were not
originally present. Palpation and percussion can alter the frequency and intensity of bowel
motility. This sequence ensures the most accurate representation of the client’s current
gastrointestinal status.
2. During a cardiovascular assessment, the nurse auscultates the S1 heart sound. Which
physiological event does this sound represent?
A. Closure of the mitral and tricuspid valves
B. Opening of the mitral and tricuspid valves
,C. Closure of the aortic and pulmonic valves
D. The beginning of diastole
Correct Answer: A
Expert Explanation: The S1 heart sound, often described as ‘lub,’ is produced by the
closure of the atrioventricular (AV) valves, which are the mitral and tricuspid valves. This
sound signals the beginning of systole when the ventricles contract. It is typically heard
loudest at the apex of the heart.
3. While assessing a client’s peripheral pulses, the nurse notes the radial pulse is weak and
easily obliterated with light pressure. How should the nurse document this finding?
A. 4+
B. 2+
C. 3+
D. 1+
Correct Answer: D
Expert Explanation: On a standard 0 to 4+ scale, a 1+ pulse indicates a weak, thready, or
diminished pulse that is easy to obliterate. A 2+ pulse is considered normal and brisk, while
0 indicates the pulse is absent. Accurate pulse grading is critical for identifying potential
vascular insufficiency or perfusion issues.
, 4. The nurse is assessing a client’s respiratory system and hears low-pitched, snoring sounds
over the bronchi during expiration. What is the correct term for this finding?
A. Fine crackles
B. Wheezes
C. Pleural friction rub
D. Rhonchi
Correct Answer: D
Expert Explanation: Rhonchi are continuous, low-pitched, rattling or snoring sounds often
caused by secretions in the larger airways. These sounds are frequently heard in patients
with chronic bronchitis or pneumonia. They can often be cleared or altered by having the
patient cough.
5. When assessing the neurological system, the nurse asks the client to follow a finger with
their eyes in the six cardinal positions of gaze. Which cranial nerves are being tested?
A. CN III, IV, and VI
B. CN II, III, and IV
C. CN V, VII, and IX
D. CN I, II, and III
Correct Answer: A
Assessment Q&A with Rationale | Fortis
College
1. A nurse is performing an abdominal assessment on a client. What is the correct sequence
of assessment techniques for this specific body system?
A. Inspection, Palpation, Percussion, Auscultation
B. Percussion, Palpation, Inspection, Auscultation
C. Auscultation, Inspection, Palpation, Percussion
D. Inspection, Auscultation, Percussion, Palpation
Correct Answer: D
Expert Explanation: In abdominal assessment, auscultation is performed before
percussion and palpation to prevent the stimulation of bowel sounds that were not
originally present. Palpation and percussion can alter the frequency and intensity of bowel
motility. This sequence ensures the most accurate representation of the client’s current
gastrointestinal status.
2. During a cardiovascular assessment, the nurse auscultates the S1 heart sound. Which
physiological event does this sound represent?
A. Closure of the mitral and tricuspid valves
B. Opening of the mitral and tricuspid valves
,C. Closure of the aortic and pulmonic valves
D. The beginning of diastole
Correct Answer: A
Expert Explanation: The S1 heart sound, often described as ‘lub,’ is produced by the
closure of the atrioventricular (AV) valves, which are the mitral and tricuspid valves. This
sound signals the beginning of systole when the ventricles contract. It is typically heard
loudest at the apex of the heart.
3. While assessing a client’s peripheral pulses, the nurse notes the radial pulse is weak and
easily obliterated with light pressure. How should the nurse document this finding?
A. 4+
B. 2+
C. 3+
D. 1+
Correct Answer: D
Expert Explanation: On a standard 0 to 4+ scale, a 1+ pulse indicates a weak, thready, or
diminished pulse that is easy to obliterate. A 2+ pulse is considered normal and brisk, while
0 indicates the pulse is absent. Accurate pulse grading is critical for identifying potential
vascular insufficiency or perfusion issues.
, 4. The nurse is assessing a client’s respiratory system and hears low-pitched, snoring sounds
over the bronchi during expiration. What is the correct term for this finding?
A. Fine crackles
B. Wheezes
C. Pleural friction rub
D. Rhonchi
Correct Answer: D
Expert Explanation: Rhonchi are continuous, low-pitched, rattling or snoring sounds often
caused by secretions in the larger airways. These sounds are frequently heard in patients
with chronic bronchitis or pneumonia. They can often be cleared or altered by having the
patient cough.
5. When assessing the neurological system, the nurse asks the client to follow a finger with
their eyes in the six cardinal positions of gaze. Which cranial nerves are being tested?
A. CN III, IV, and VI
B. CN II, III, and IV
C. CN V, VII, and IX
D. CN I, II, and III
Correct Answer: A
