NUR 101/NUR101 Exam 2 V3 | Health Assessment
Q&A with Rationale | Fortis College
1. When performing an abdominal assessment, in which order should the nurse conduct the
exam components?
A. Inspection, Palpation, Percussion, Auscultation
B. Inspection, Auscultation, Percussion, Palpation
C. Auscultation, Inspection, Percussion, Palpation
D. Palpation, Percussion, Auscultation, Inspection
Correct Answer: B
Explanation: The standard order for abdominal assessment is altered to ensure bowel
sounds are not artificially induced by physical manipulation. Auscultation is performed
second because percussion and palpation can increase peristalsis and alter the findings.
This specific sequence is essential for providing an accurate clinical picture of the patient’s
gastrointestinal function.
2. A nurse is auscultating the 2nd intercostal space at the right sternal border. Which heart
valve is best heard in this location?
A. Mitral valve
B. Aortic valve
C. Pulmonic valve
,D. Tricuspid valve
Correct Answer: B
Explanation: The aortic valve area is located at the second right intercostal space along the
sternal border. This is the primary site for hearing S2 and detecting aortic murmurs.
Properly identifying these landmarks is a fundamental skill for cardiovascular health
assessment in nursing.
3. Which finding would a nurse document as a normal finding for the Romberg test?
A. The patient sways significantly and loses balance.
B. The patient is unable to stand with feet together.
C. The patient stands with minimal swaying for at least 20 seconds.
D. The patient experiences dizziness when eyes are closed.
Correct Answer: C
Explanation: A negative Romberg test means the patient maintains balance with minimal
swaying while standing with feet together and eyes closed. This test assesses the integrity
of the cerebellum and vestibular system. Significant swaying or loss of balance would
indicate a positive Romberg, suggesting neurological impairment.
4. During a respiratory assessment, the nurse notes a high-pitched, musical whistling sound
during expiration. This sound is characterized as:
A. Coarse crackles
, B. Stridor
C. Pleural friction rub
D. Wheezes
Correct Answer: D
Explanation: Wheezes are continuous, high-pitched musical sounds typically heard during
expiration when air flows through narrowed airways. They are commonly associated with
conditions like asthma or chronic obstructive pulmonary disease. Accurate identification
and documentation of adventitious sounds are critical for monitoring respiratory status.
5. The nurse is assessing a patient’s muscle strength and notes the patient has active motion
against full resistance. How should this be graded?
A. 3/5
B. 4/5
C. 2/5
D. 5/5
Correct Answer: D
Explanation: A grade of 5/5 indicates normal muscle strength with full range of motion
against gravity and full resistance. Grade 4 indicates full range of motion against gravity
with some resistance, while Grade 3 is motion against gravity only. Using the 0 to 5 scale
allows nurses to objectively quantify and track a patient’s motor function over time.
Q&A with Rationale | Fortis College
1. When performing an abdominal assessment, in which order should the nurse conduct the
exam components?
A. Inspection, Palpation, Percussion, Auscultation
B. Inspection, Auscultation, Percussion, Palpation
C. Auscultation, Inspection, Percussion, Palpation
D. Palpation, Percussion, Auscultation, Inspection
Correct Answer: B
Explanation: The standard order for abdominal assessment is altered to ensure bowel
sounds are not artificially induced by physical manipulation. Auscultation is performed
second because percussion and palpation can increase peristalsis and alter the findings.
This specific sequence is essential for providing an accurate clinical picture of the patient’s
gastrointestinal function.
2. A nurse is auscultating the 2nd intercostal space at the right sternal border. Which heart
valve is best heard in this location?
A. Mitral valve
B. Aortic valve
C. Pulmonic valve
,D. Tricuspid valve
Correct Answer: B
Explanation: The aortic valve area is located at the second right intercostal space along the
sternal border. This is the primary site for hearing S2 and detecting aortic murmurs.
Properly identifying these landmarks is a fundamental skill for cardiovascular health
assessment in nursing.
3. Which finding would a nurse document as a normal finding for the Romberg test?
A. The patient sways significantly and loses balance.
B. The patient is unable to stand with feet together.
C. The patient stands with minimal swaying for at least 20 seconds.
D. The patient experiences dizziness when eyes are closed.
Correct Answer: C
Explanation: A negative Romberg test means the patient maintains balance with minimal
swaying while standing with feet together and eyes closed. This test assesses the integrity
of the cerebellum and vestibular system. Significant swaying or loss of balance would
indicate a positive Romberg, suggesting neurological impairment.
4. During a respiratory assessment, the nurse notes a high-pitched, musical whistling sound
during expiration. This sound is characterized as:
A. Coarse crackles
, B. Stridor
C. Pleural friction rub
D. Wheezes
Correct Answer: D
Explanation: Wheezes are continuous, high-pitched musical sounds typically heard during
expiration when air flows through narrowed airways. They are commonly associated with
conditions like asthma or chronic obstructive pulmonary disease. Accurate identification
and documentation of adventitious sounds are critical for monitoring respiratory status.
5. The nurse is assessing a patient’s muscle strength and notes the patient has active motion
against full resistance. How should this be graded?
A. 3/5
B. 4/5
C. 2/5
D. 5/5
Correct Answer: D
Explanation: A grade of 5/5 indicates normal muscle strength with full range of motion
against gravity and full resistance. Grade 4 indicates full range of motion against gravity
with some resistance, while Grade 3 is motion against gravity only. Using the 0 to 5 scale
allows nurses to objectively quantify and track a patient’s motor function over time.
