NSG121/NSG 121 Exam 3 V2 | Health
Assessment Q&A with Rationale | Herzing
University
1. When performing a physical assessment of the abdomen, in what order should the nurse
perform the examination techniques?
A. Inspection, Palpation, Percussion, Auscultation
B. Auscultation, Inspection, Palpation, Percussion
C. Inspection, Auscultation, Percussion, Palpation
D. Percussion, Palpation, Inspection, Auscultation
Correct Answer: C
Rationale: The correct sequence for abdominal assessment is inspection, auscultation,
percussion, and then palpation. This order is strictly followed because percussion and
palpation can increase peristalsis, which would give a false interpretation of bowel sounds.
By auscultating before touching the abdomen, the nurse ensures the most accurate
assessment of natural bowel activity.
2. A nurse is assessing a patient for possible appendicitis. Which technique should the nurse
use to assess for rebound tenderness?
A. Deeply palpate the left lower quadrant and quickly release
B. Perform deep palpation at a 90-degree angle and withdraw the hand quickly
,C. Gently tap the costovertebral angle
D. Use the bell of the stethoscope to listen for bruits in the iliac area
Correct Answer: B
Rationale: Rebound tenderness, also known as Blumberg’s sign, is assessed by pressing
deeply and steadily into the abdomen at a 90-degree angle and then releasing quickly. Pain
upon release is a positive finding and suggests peritoneal inflammation, which is common
in appendicitis. This assessment should be performed at the end of the examination
because it can cause significant discomfort.
3. During a cardiac assessment, the nurse hears the S1 heart sound most clearly at which
anatomical location?
A. Second right intercostal space
B. Second left intercostal space
C. Fourth intercostal space at the left sternal border
D. Fifth intercostal space at the left midclavicular line
Correct Answer: D
Rationale: The S1 heart sound, which represents the closure of the atrioventricular valves,
is best heard at the apex of the heart. The apex is located at the fifth intercostal space, left
midclavicular line. This sound coincides with the carotid artery pulse and marks the
beginning of systole.
, 4. A nurse is evaluating a patient’s peripheral pulses and notes that the radial pulse is easily
palpable but can be obliterated with strong pressure. How should the nurse document this
finding?
A. 1+
B. 2+
C. 3+
D. 4+
Correct Answer: B
Rationale: A 2+ pulse is considered normal and expected, characterized by being easily
palpable but capable of being obliterated with firm pressure. A 1+ pulse is weak or thready,
while a 3+ pulse is full or bounding. Consistent documentation using the standard 0 to 4+
scale is essential for tracking changes in a patient’s hemodynamic status.
5. Which assessment finding would the nurse expect to see in a patient with chronic venous
insufficiency?
A. Brownish discoloration of the skin around the ankles
B. Pale, cool skin with diminished pulses
C. Thin, shiny skin with loss of hair on the lower legs
D. Gangrene on the tips of the toes
Correct Answer: A
Assessment Q&A with Rationale | Herzing
University
1. When performing a physical assessment of the abdomen, in what order should the nurse
perform the examination techniques?
A. Inspection, Palpation, Percussion, Auscultation
B. Auscultation, Inspection, Palpation, Percussion
C. Inspection, Auscultation, Percussion, Palpation
D. Percussion, Palpation, Inspection, Auscultation
Correct Answer: C
Rationale: The correct sequence for abdominal assessment is inspection, auscultation,
percussion, and then palpation. This order is strictly followed because percussion and
palpation can increase peristalsis, which would give a false interpretation of bowel sounds.
By auscultating before touching the abdomen, the nurse ensures the most accurate
assessment of natural bowel activity.
2. A nurse is assessing a patient for possible appendicitis. Which technique should the nurse
use to assess for rebound tenderness?
A. Deeply palpate the left lower quadrant and quickly release
B. Perform deep palpation at a 90-degree angle and withdraw the hand quickly
,C. Gently tap the costovertebral angle
D. Use the bell of the stethoscope to listen for bruits in the iliac area
Correct Answer: B
Rationale: Rebound tenderness, also known as Blumberg’s sign, is assessed by pressing
deeply and steadily into the abdomen at a 90-degree angle and then releasing quickly. Pain
upon release is a positive finding and suggests peritoneal inflammation, which is common
in appendicitis. This assessment should be performed at the end of the examination
because it can cause significant discomfort.
3. During a cardiac assessment, the nurse hears the S1 heart sound most clearly at which
anatomical location?
A. Second right intercostal space
B. Second left intercostal space
C. Fourth intercostal space at the left sternal border
D. Fifth intercostal space at the left midclavicular line
Correct Answer: D
Rationale: The S1 heart sound, which represents the closure of the atrioventricular valves,
is best heard at the apex of the heart. The apex is located at the fifth intercostal space, left
midclavicular line. This sound coincides with the carotid artery pulse and marks the
beginning of systole.
, 4. A nurse is evaluating a patient’s peripheral pulses and notes that the radial pulse is easily
palpable but can be obliterated with strong pressure. How should the nurse document this
finding?
A. 1+
B. 2+
C. 3+
D. 4+
Correct Answer: B
Rationale: A 2+ pulse is considered normal and expected, characterized by being easily
palpable but capable of being obliterated with firm pressure. A 1+ pulse is weak or thready,
while a 3+ pulse is full or bounding. Consistent documentation using the standard 0 to 4+
scale is essential for tracking changes in a patient’s hemodynamic status.
5. Which assessment finding would the nurse expect to see in a patient with chronic venous
insufficiency?
A. Brownish discoloration of the skin around the ankles
B. Pale, cool skin with diminished pulses
C. Thin, shiny skin with loss of hair on the lower legs
D. Gangrene on the tips of the toes
Correct Answer: A
