NUR 101/NUR101 Exam 3 V2 | Health Assessment
Q&A with Rationale | Fortis College
1. When assessing a patient’s lungs, the nurse hears soft, low-pitched sounds over the
majority of the peripheral lung fields. How should these be documented?
A. Bronchial breath sounds
B. Bronchovesicular breath sounds
C. Vesicular breath sounds
D. Adventitious breath sounds
Correct Answer: C
Explanation: Vesicular breath sounds are the normal sounds heard over most of the lung
surface. They are characterized by a soft, rustling quality with a longer inspiratory phase
than expiratory phase. Hearing these in the periphery indicates healthy lung tissue and
normal airflow.
2. During an abdominal assessment, in which order should the nurse perform the physical
examination techniques?
A. Inspection, Palpation, Percussion, Auscultation
B. Auscultation, Inspection, Palpation, Percussion
C. Inspection, Auscultation, Percussion, Palpation
D. Percussion, Auscultation, Inspection, Palpation
,Correct Answer: C
Explanation: The abdomen is assessed using the sequence of inspection, auscultation,
percussion, and then palpation. This specific order is used because palpation and
percussion can stimulate peristalsis and alter bowel sounds. By auscultating second, the
nurse obtains a more accurate representation of the patient’s natural bowel activity.
3. A nurse is grading a patient’s peripheral pulses and finds them to be ‘weak and thready.’
Which numerical grade should the nurse assign?
A. 0
B. 1+
C. 2+
D. 3+
Correct Answer: B
Explanation: On the standard 4-point scale, a 1+ grade indicates a weak, thready, or
diminished pulse that is difficult to palpate. A 2+ grade represents a normal, brisk pulse,
while 3+ or 4+ represents a full, bounding pulse. This assessment is critical for determining
the adequacy of peripheral arterial circulation.
4. Where is the best anatomical location for the nurse to auscultate the S1 heart sound?
A. Second intercostal space, right sternal border
B. Second intercostal space, left sternal border
, C. Fifth intercostal space, left midclavicular line
D. Fourth intercostal space, left sternal border
Correct Answer: C
Explanation: The S1 heart sound, which represents the closure of the atrioventricular
valves, is loudest at the apex of the heart. The apex is typically located at the fifth
intercostal space at the left midclavicular line. This location corresponds to the mitral valve
area where the ‘lub’ sound is most prominent.
5. A nurse notes a patient has a ‘barrel chest.’ What is the expected anteroposterior (AP) to
transverse diameter ratio for this patient?
A. 2:1
B. 1:2
C. 1:1
D. 1:3
Correct Answer: C
Explanation: A normal adult chest has an AP to transverse ratio of approximately 1:2. In
patients with barrel chest, often seen in chronic obstructive pulmonary disease (COPD), the
AP diameter increases until it equals the transverse diameter, resulting in a 1:1 ratio. This
structural change reflects chronic air trapping and hyperinflation of the lungs.
Q&A with Rationale | Fortis College
1. When assessing a patient’s lungs, the nurse hears soft, low-pitched sounds over the
majority of the peripheral lung fields. How should these be documented?
A. Bronchial breath sounds
B. Bronchovesicular breath sounds
C. Vesicular breath sounds
D. Adventitious breath sounds
Correct Answer: C
Explanation: Vesicular breath sounds are the normal sounds heard over most of the lung
surface. They are characterized by a soft, rustling quality with a longer inspiratory phase
than expiratory phase. Hearing these in the periphery indicates healthy lung tissue and
normal airflow.
2. During an abdominal assessment, in which order should the nurse perform the physical
examination techniques?
A. Inspection, Palpation, Percussion, Auscultation
B. Auscultation, Inspection, Palpation, Percussion
C. Inspection, Auscultation, Percussion, Palpation
D. Percussion, Auscultation, Inspection, Palpation
,Correct Answer: C
Explanation: The abdomen is assessed using the sequence of inspection, auscultation,
percussion, and then palpation. This specific order is used because palpation and
percussion can stimulate peristalsis and alter bowel sounds. By auscultating second, the
nurse obtains a more accurate representation of the patient’s natural bowel activity.
3. A nurse is grading a patient’s peripheral pulses and finds them to be ‘weak and thready.’
Which numerical grade should the nurse assign?
A. 0
B. 1+
C. 2+
D. 3+
Correct Answer: B
Explanation: On the standard 4-point scale, a 1+ grade indicates a weak, thready, or
diminished pulse that is difficult to palpate. A 2+ grade represents a normal, brisk pulse,
while 3+ or 4+ represents a full, bounding pulse. This assessment is critical for determining
the adequacy of peripheral arterial circulation.
4. Where is the best anatomical location for the nurse to auscultate the S1 heart sound?
A. Second intercostal space, right sternal border
B. Second intercostal space, left sternal border
, C. Fifth intercostal space, left midclavicular line
D. Fourth intercostal space, left sternal border
Correct Answer: C
Explanation: The S1 heart sound, which represents the closure of the atrioventricular
valves, is loudest at the apex of the heart. The apex is typically located at the fifth
intercostal space at the left midclavicular line. This location corresponds to the mitral valve
area where the ‘lub’ sound is most prominent.
5. A nurse notes a patient has a ‘barrel chest.’ What is the expected anteroposterior (AP) to
transverse diameter ratio for this patient?
A. 2:1
B. 1:2
C. 1:1
D. 1:3
Correct Answer: C
Explanation: A normal adult chest has an AP to transverse ratio of approximately 1:2. In
patients with barrel chest, often seen in chronic obstructive pulmonary disease (COPD), the
AP diameter increases until it equals the transverse diameter, resulting in a 1:1 ratio. This
structural change reflects chronic air trapping and hyperinflation of the lungs.
