NUR 101/NUR101 Exam 2 V2 | Health Assessment
Q&A with Rationale | Fortis College
1. The nurse is identifying the landmark for the second intercostal space. Which anatomical
structure should be located first?
A. The Xiphoid process
B. The Suprasternal notch
C. The Clavicle
D. The Sternal angle (Angle of Louis)
Correct Answer: D
Explanation: The sternal angle, also known as the angle of Louis, is the articulation of the
manubrium and body of the sternum. It is continuous with the second rib, which makes it
the standard landmark to begin counting ribs and intercostal spaces. Correct identification
is essential for accurate auscultation of heart and lung sounds.
2. When assessing for tactile fremitus, the nurse should instruct the patient to repeat which
phrase?
A. One, two, three
B. Ninety-nine
C. Blue moon
D. E-E-E
,Correct Answer: B
Explanation: Tactile fremitus is a palpable vibration transmitted through the
bronchopulmonary system to the chest wall. The phrase ‘ninety-nine’ or ‘blue moon’
generates strong vibrations that are easily felt by the nurse’s hands. The nurse should use
the palmar base of the fingers or the ulnar edge of the hand for maximum sensitivity.
3. The nurse auscultates high-pitched, musical sounds primarily during expiration. How
should this finding be documented?
A. Crackles
B. Wheezes
C. Rhonchi
D. Pleural friction rub
Correct Answer: B
Explanation: Wheezes are high-pitched, musical whistling sounds caused by air squeezing
through narrowed or obstructed airways. They are most commonly heard during
expiration but can occur during inspiration in severe cases. This finding is characteristic of
conditions like asthma or chronic obstructive pulmonary disease.
4. During a cardiac assessment, the nurse notes a ‘thrill.’ What is the nurse actually feeling?
A. A normal heart contraction
B. A palpable vibration
, C. A faint heart murmur
D. An enlarged lymph node
Correct Answer: B
Explanation: A thrill is a palpable vibration that often accompanies loud heart murmurs,
signifying turbulent blood flow. It feels similar to the purring of a cat and is assessed using
the palmar aspect of the hand. The presence of a thrill usually indicates a murmur of grade
IV or higher.
5. Where is the apical pulse located in a healthy adult?
A. Second intercostal space, right sternal border
B. Fourth intercostal space, left sternal border
C. Second intercostal space, left sternal border
D. Fifth intercostal space, left midclavicular line
Correct Answer: D
Explanation: The apical pulse, or the point of maximal impulse (PMI), is typically found at
the fifth intercostal space at or just medial to the left midclavicular line. It represents the
pulsation of the left ventricle against the chest wall during systole. In cases of cardiac
enlargement, this point may be displaced further down or to the left.
Q&A with Rationale | Fortis College
1. The nurse is identifying the landmark for the second intercostal space. Which anatomical
structure should be located first?
A. The Xiphoid process
B. The Suprasternal notch
C. The Clavicle
D. The Sternal angle (Angle of Louis)
Correct Answer: D
Explanation: The sternal angle, also known as the angle of Louis, is the articulation of the
manubrium and body of the sternum. It is continuous with the second rib, which makes it
the standard landmark to begin counting ribs and intercostal spaces. Correct identification
is essential for accurate auscultation of heart and lung sounds.
2. When assessing for tactile fremitus, the nurse should instruct the patient to repeat which
phrase?
A. One, two, three
B. Ninety-nine
C. Blue moon
D. E-E-E
,Correct Answer: B
Explanation: Tactile fremitus is a palpable vibration transmitted through the
bronchopulmonary system to the chest wall. The phrase ‘ninety-nine’ or ‘blue moon’
generates strong vibrations that are easily felt by the nurse’s hands. The nurse should use
the palmar base of the fingers or the ulnar edge of the hand for maximum sensitivity.
3. The nurse auscultates high-pitched, musical sounds primarily during expiration. How
should this finding be documented?
A. Crackles
B. Wheezes
C. Rhonchi
D. Pleural friction rub
Correct Answer: B
Explanation: Wheezes are high-pitched, musical whistling sounds caused by air squeezing
through narrowed or obstructed airways. They are most commonly heard during
expiration but can occur during inspiration in severe cases. This finding is characteristic of
conditions like asthma or chronic obstructive pulmonary disease.
4. During a cardiac assessment, the nurse notes a ‘thrill.’ What is the nurse actually feeling?
A. A normal heart contraction
B. A palpable vibration
, C. A faint heart murmur
D. An enlarged lymph node
Correct Answer: B
Explanation: A thrill is a palpable vibration that often accompanies loud heart murmurs,
signifying turbulent blood flow. It feels similar to the purring of a cat and is assessed using
the palmar aspect of the hand. The presence of a thrill usually indicates a murmur of grade
IV or higher.
5. Where is the apical pulse located in a healthy adult?
A. Second intercostal space, right sternal border
B. Fourth intercostal space, left sternal border
C. Second intercostal space, left sternal border
D. Fifth intercostal space, left midclavicular line
Correct Answer: D
Explanation: The apical pulse, or the point of maximal impulse (PMI), is typically found at
the fifth intercostal space at or just medial to the left midclavicular line. It represents the
pulsation of the left ventricle against the chest wall during systole. In cases of cardiac
enlargement, this point may be displaced further down or to the left.
