NUR 101/ NUR101 Exam 2 – Health
Assessment Guide | Fortis (Latest 2026/ 2027
Update) 100% Verified Questions & Answers |
Grade A
EXAM OVERVIEW
Course: NUR 101 Health Assessment
Institution: Fortis College
Exam: Exam 2 (Version 3 / Latest Edition)
Academic Year: 2026–2027
Format: 150+ Questions with Verified Answers and Detailed Rationales
Topics Covered: System-focused examinations, clinical judgment, respiratory assessment,
cardiovascular assessment, neurological assessment, documentation, patient-centered care,
and professional ethics
SECTION 1: RESPIRATORY ASSESSMENT (Questions 1–30)
1. The nurse auscultates a client with soft, high-pitched popping breath sounds on inspiration.
The nurse documents the breath sounds heard as:
A) Wheezes
B) Rhonchi
C) Crackles
D) Stridor
Correct Answer: C
Rationale: Crackles (formerly called rales) are soft, high-pitched, discontinuous popping sounds
heard primarily during inspiration. They indicate the opening of collapsed airways or fluid in the
alveoli. Wheezes are continuous musical sounds. Rhonchi are lower-pitched snoring sounds.
Stridor is a harsh, high-pitched sound heard with upper airway obstruction .
,2. Which medication is administered in the home or the hospital to relieve inflammation in
the lung tissue?
A) Bronchodilators
B) Corticosteroids
C) Antitussives
D) Expectorants
Correct Answer: B
Rationale: Corticosteroids reduce inflammation in lung tissue and are used to treat asthma,
COPD, and other inflammatory respiratory conditions. They can be administered orally,
intravenously, or via inhalation .
3. The nurse is caring for a client who has a compromised cardiopulmonary system and needs
to assess the client's tissue oxygenation. The nurse would use which appropriate method to
assess this client's oxygenation?
A) Pulse oximetry
B) Capnography
C) Arterial blood gas
D) Chest auscultation
Correct Answer: C
Rationale: Arterial blood gas (ABG) analysis provides the most comprehensive assessment of
tissue oxygenation, including PaO2, SaO2, PaCO2, pH, and bicarbonate levels. While pulse
oximetry provides continuous monitoring, ABG is the gold standard for evaluating oxygenation
and acid-base status in compromised patients .
4. The nurse is caring for a client with metabolic acidosis whose breathing rate is 28 breaths
per minute. Which arterial blood gas data does the nurse anticipate finding?
A) pH less than 7.35; HCO3 low; PaCO2 low
B) pH greater than 7.45; HCO3 high; PaCO2 high
C) pH less than 7.35; HCO3 high; PaCO2 normal
D) pH greater than 7.45; HCO3 low; PaCO2 low
Correct Answer: A
,Rationale: Metabolic acidosis is characterized by a low pH (<7.35), low HCO3 (<22 mEq/L), and
compensatory low PaCO2 (due to hyperventilation/Kussmaul respirations) .
5. A client is reporting slight shortness of breath and lung auscultation reveals the presence of
bilateral coarse crackles. The client's SaO2 is 90% on pulse oximetry. The nurse has applied
supplementary oxygen by nasal cannula, recognizing that the flow rate by this method should
not exceed:
A) 2 L per minute
B) 4 L per minute
C) 6 L per minute
D) 8 L per minute
Correct Answer: C
Rationale: Nasal cannula flow rates should not exceed 6 L per minute because higher flow rates
can cause drying of mucous membranes and patient discomfort. Flow rates above 6 L/min
typically require alternative delivery systems such as simple masks or Venturi masks .
6. A client with a diagnosis of advanced Alzheimer disease is unable to follow directions
required to use an inhaled bronchodilator. Which medication delivery system is most
appropriate for this client?
A) Metered-dose inhaler (MDI) with spacer
B) Dry powder inhaler (DPI)
C) Nebulizer
D) Soft mist inhaler
Correct Answer: C
Rationale: A nebulizer is the most appropriate delivery system for a client who cannot follow
directions for coordinated inhalation. The nebulizer requires minimal patient cooperation—only
passive breathing through a mouthpiece or mask .
7. When auscultating breath sounds, which instruction should the nurse give the client?
A) "Hold your breath for 10 seconds"
B) "Take slow, deep breaths through your mouth"
, C) "Breathe normally through your nose"
D) "Cough deeply between auscultation points"
Correct Answer: B
Rationale: Asking the client to take slow, deep breaths through an open mouth increases airflow
and enhances breath sounds, making them easier to auscultate and assess for abnormalities.
8. The nurse documents "adventitious breath sounds" in the client's chart. This term refers to:
A) Normal breath sounds
B) Abnormal breath sounds added to normal breath sounds
C) Absent breath sounds
D) Bronchial breath sounds in peripheral lung fields
Correct Answer: B
Rationale: Adventitious breath sounds are abnormal sounds added to normal breath sounds,
such as crackles, wheezes, rhonchi, and pleural friction rubs.
9. A client with chronic obstructive pulmonary disease (COPD) is likely to exhibit which
breathing pattern?
A) Kussmaul respirations
B) Cheyne-Stokes respirations
C) Pursed-lip breathing
D) Biot's respirations
Correct Answer: C
Rationale: Pursed-lip breathing is a compensatory mechanism used by COPD clients to create
positive end-expiratory pressure, which helps keep airways open and improves gas exchange.
10. The normal PaO2 value for a healthy adult is:
A) 60-70 mm Hg
B) 70-80 mm Hg
C) 80-100 mm Hg
D) 100-120 mm Hg
Assessment Guide | Fortis (Latest 2026/ 2027
Update) 100% Verified Questions & Answers |
Grade A
EXAM OVERVIEW
Course: NUR 101 Health Assessment
Institution: Fortis College
Exam: Exam 2 (Version 3 / Latest Edition)
Academic Year: 2026–2027
Format: 150+ Questions with Verified Answers and Detailed Rationales
Topics Covered: System-focused examinations, clinical judgment, respiratory assessment,
cardiovascular assessment, neurological assessment, documentation, patient-centered care,
and professional ethics
SECTION 1: RESPIRATORY ASSESSMENT (Questions 1–30)
1. The nurse auscultates a client with soft, high-pitched popping breath sounds on inspiration.
The nurse documents the breath sounds heard as:
A) Wheezes
B) Rhonchi
C) Crackles
D) Stridor
Correct Answer: C
Rationale: Crackles (formerly called rales) are soft, high-pitched, discontinuous popping sounds
heard primarily during inspiration. They indicate the opening of collapsed airways or fluid in the
alveoli. Wheezes are continuous musical sounds. Rhonchi are lower-pitched snoring sounds.
Stridor is a harsh, high-pitched sound heard with upper airway obstruction .
,2. Which medication is administered in the home or the hospital to relieve inflammation in
the lung tissue?
A) Bronchodilators
B) Corticosteroids
C) Antitussives
D) Expectorants
Correct Answer: B
Rationale: Corticosteroids reduce inflammation in lung tissue and are used to treat asthma,
COPD, and other inflammatory respiratory conditions. They can be administered orally,
intravenously, or via inhalation .
3. The nurse is caring for a client who has a compromised cardiopulmonary system and needs
to assess the client's tissue oxygenation. The nurse would use which appropriate method to
assess this client's oxygenation?
A) Pulse oximetry
B) Capnography
C) Arterial blood gas
D) Chest auscultation
Correct Answer: C
Rationale: Arterial blood gas (ABG) analysis provides the most comprehensive assessment of
tissue oxygenation, including PaO2, SaO2, PaCO2, pH, and bicarbonate levels. While pulse
oximetry provides continuous monitoring, ABG is the gold standard for evaluating oxygenation
and acid-base status in compromised patients .
4. The nurse is caring for a client with metabolic acidosis whose breathing rate is 28 breaths
per minute. Which arterial blood gas data does the nurse anticipate finding?
A) pH less than 7.35; HCO3 low; PaCO2 low
B) pH greater than 7.45; HCO3 high; PaCO2 high
C) pH less than 7.35; HCO3 high; PaCO2 normal
D) pH greater than 7.45; HCO3 low; PaCO2 low
Correct Answer: A
,Rationale: Metabolic acidosis is characterized by a low pH (<7.35), low HCO3 (<22 mEq/L), and
compensatory low PaCO2 (due to hyperventilation/Kussmaul respirations) .
5. A client is reporting slight shortness of breath and lung auscultation reveals the presence of
bilateral coarse crackles. The client's SaO2 is 90% on pulse oximetry. The nurse has applied
supplementary oxygen by nasal cannula, recognizing that the flow rate by this method should
not exceed:
A) 2 L per minute
B) 4 L per minute
C) 6 L per minute
D) 8 L per minute
Correct Answer: C
Rationale: Nasal cannula flow rates should not exceed 6 L per minute because higher flow rates
can cause drying of mucous membranes and patient discomfort. Flow rates above 6 L/min
typically require alternative delivery systems such as simple masks or Venturi masks .
6. A client with a diagnosis of advanced Alzheimer disease is unable to follow directions
required to use an inhaled bronchodilator. Which medication delivery system is most
appropriate for this client?
A) Metered-dose inhaler (MDI) with spacer
B) Dry powder inhaler (DPI)
C) Nebulizer
D) Soft mist inhaler
Correct Answer: C
Rationale: A nebulizer is the most appropriate delivery system for a client who cannot follow
directions for coordinated inhalation. The nebulizer requires minimal patient cooperation—only
passive breathing through a mouthpiece or mask .
7. When auscultating breath sounds, which instruction should the nurse give the client?
A) "Hold your breath for 10 seconds"
B) "Take slow, deep breaths through your mouth"
, C) "Breathe normally through your nose"
D) "Cough deeply between auscultation points"
Correct Answer: B
Rationale: Asking the client to take slow, deep breaths through an open mouth increases airflow
and enhances breath sounds, making them easier to auscultate and assess for abnormalities.
8. The nurse documents "adventitious breath sounds" in the client's chart. This term refers to:
A) Normal breath sounds
B) Abnormal breath sounds added to normal breath sounds
C) Absent breath sounds
D) Bronchial breath sounds in peripheral lung fields
Correct Answer: B
Rationale: Adventitious breath sounds are abnormal sounds added to normal breath sounds,
such as crackles, wheezes, rhonchi, and pleural friction rubs.
9. A client with chronic obstructive pulmonary disease (COPD) is likely to exhibit which
breathing pattern?
A) Kussmaul respirations
B) Cheyne-Stokes respirations
C) Pursed-lip breathing
D) Biot's respirations
Correct Answer: C
Rationale: Pursed-lip breathing is a compensatory mechanism used by COPD clients to create
positive end-expiratory pressure, which helps keep airways open and improves gas exchange.
10. The normal PaO2 value for a healthy adult is:
A) 60-70 mm Hg
B) 70-80 mm Hg
C) 80-100 mm Hg
D) 100-120 mm Hg
