Bank (Latest 2026/2027 Edition) – Questions, Answers &
Detailed Rationales
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SECTION 1: ASSESSMENT TECHNIQUES & SAFETY
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Question 1
Which technique is used to assess the size, consistency, and mobility of an underlying
organ or mass by pressing the fingertips against the body surface?
A. Percussion
B. Palpation ✓
C. Auscultation
D. Inspection
Correct Answer: B — Palpation
Rationale: Palpation involves using the hands and fingers to feel body surfaces for size,
shape, consistency, mobility, and tenderness of underlying structures. Percussion
assesses density and borders, auscultation listens to body sounds, and inspection is
visual examination.
Question 2
A nursing student is preparing to perform a physical examination on a 68-year-old
patient. Which action demonstrates correct infection control and safety protocol?
A. Donning clean gloves before touching any body surface
B. Performing hand hygiene before and after patient contact ✓
C. Wearing a surgical mask throughout the entire examination
,D. Using sterile technique for all palpation techniques
Correct Answer: B — Performing hand hygiene before and after patient contact
Rationale: Standard precautions require hand hygiene before and after every patient
contact as the most effective method to prevent healthcare-associated infections.
Clean gloves are used when contact with blood, body fluids, or non-intact skin is
anticipated, not for routine examination of intact skin.
Question 3
During auscultation of the abdomen, the nurse practitioner hears high-pitched, gurgling
sounds occurring 5–34 times per minute. Which interpretation is most accurate?
A. Diminished bowel sounds indicating ileus
B. Normal bowel sounds ✓
C. Hyperactive bowel sounds indicating obstruction
D. Friction rub suggesting peritoneal inflammation
Correct Answer: B — Normal bowel sounds
Rationale: Normal bowel sounds are high-pitched, gurgling sounds heard 5–34 times
per minute. Diminished sounds occur <5 times per minute, hyperactive sounds are >34
times per minute and may indicate early obstruction, and friction rubs are rare, harsh
sounds suggesting peritoneal inflammation.
Question 4
A nurse is preparing to assess a patient's blood pressure. The patient has just walked
up two flights of stairs and is visibly short of breath. Which action is most appropriate?
A. Proceed with the blood pressure assessment immediately to obtain a baseline
B. Allow the patient to rest for 5 minutes before measuring blood pressure ✓
C. Document that the blood pressure cannot be obtained due to patient activity
,D. Elevate the patient's legs and measure blood pressure in that position
Correct Answer: B — Allow the patient to rest for 5 minutes before measuring blood
pressure
Rationale: Blood pressure should be measured after the patient has rested for at least 5
minutes in a seated position with feet flat on the floor to ensure accuracy. Recent
physical activity, smoking, caffeine, or emotional stress can falsely elevate readings.
Question 5
Which position is most appropriate for assessing the rectum and performing a rectal
examination?
A. Supine with knees extended
B. Left lateral Sims' position with knees flexed ✓
C. Prone with hips elevated
D. Sitting upright with feet dangling
Correct Answer: B — Left lateral Sims' position with knees flexed
Rationale: The left lateral Sims' position places the patient on their left side with the
right knee flexed toward the chest, providing optimal exposure and comfort for rectal
examination. This position allows gravity to assist with visualization and reduces
patient embarrassment.
Question 6
A nurse is using the diaphragm of the stethoscope to auscultate heart sounds. Which
characteristic best describes the sounds best heard with the diaphragm?
A. Low-pitched sounds such as S3 and S4 gallops
B. High-pitched sounds such as S1, S2, and murmurs ✓
C. Very low-frequency sounds such as venous hums
, D. Dull percussion notes over the liver
Correct Answer: B — High-pitched sounds such as S1, S2, and murmurs
Rationale: The diaphragm of the stethoscope is designed to accentuate high-pitched
sounds including S1, S2, and most murmurs. The bell is used for low-pitched sounds
such as S3, S4, and the mitral stenosis murmur. Firm pressure is required when using
the diaphragm.
Question 7
During percussion of the chest, the nurse hears a resonant sound. Which structure is
most likely being percussed?
A. The liver
B. Normal lung tissue ✓
C. A large pleural effusion
D. The gastric bubble
Correct Answer: B — Normal lung tissue
Rationale: Resonance is the normal percussion note heard over healthy lung tissue due
to air-filled alveoli. The liver produces a dull sound, a large pleural effusion produces
flatness, and the gastric bubble produces tympany. Percussion notes help identify
abnormal densities and air collections.
Question 8
A nurse is assessing a patient who reports pain rated 8/10 in the right lower quadrant.
Which assessment technique should be performed last in this abdominal examination?
A. Inspection of the abdomen for contour and symmetry
B. Auscultation of bowel sounds
C. Percussion to assess for organomegaly