NUR 101/NUR101 Exam 3 V1 | Health Assessment
Q&A with Rationale | Fortis College
1. When performing an abdominal assessment, in which order should the nurse perform the
physical examination techniques?
A. Inspection, Palpation, Percussion, Auscultation
B. Inspection, Auscultation, Percussion, Palpation
C. Auscultation, Inspection, Palpation, Percussion
D. Percussion, Auscultation, Inspection, Palpation
Correct Answer: B
Explanation: The correct order for abdominal assessment is inspection, followed by
auscultation, percussion, and finally palpation. Auscultation is performed before
percussion and palpation because manual manipulation of the abdomen can stimulate
peristalsis and alter bowel sounds. This sequence is essential to ensure the nurse obtains
the most accurate clinical data regarding the patient’s bowel activity.
2. To assess the patient’s apical pulse, where should the nurse place the stethoscope?
A. Second intercostal space, right sternal border
B. Fifth intercostal space, left midclavicular line
C. Fourth intercostal space, left sternal border
D. Second intercostal space, left sternal border
,Correct Answer: B
Explanation: The apical pulse is best auscultated at the mitral area, located at the fifth
intercostal space at the left midclavicular line. This location represents the point of
maximal impulse where the left ventricle is closest to the chest wall. Locating this landmark
accurately is a critical skill for assessing heart rate and rhythm in the NUR 101 clinical
setting.
3. During a respiratory assessment, the nurse hears high-pitched, musical sounds primarily
during expiration. How should the nurse document this finding?
A. Crackles
B. Wheezes
C. Rhonchi
D. Pleural friction rub
Correct Answer: B
Explanation: Wheezes are continuous, high-pitched musical sounds caused by air flowing
through narrowed or obstructed airways. They are most commonly heard during
expiration but can also occur during inspiration. The nurse must distinguish these from
crackles, which are discontinuous popping sounds associated with fluid in the alveoli.
4. Which heart sound is produced by the closure of the atrioventricular (AV) valves?
A. S3
B. S2
, C. S1
D. S4
Correct Answer: C
Explanation: The S1 heart sound, often described as ‘lub,’ marks the beginning of systole
and is caused by the closure of the mitral and tricuspid valves. It is usually loudest at the
apex of the heart. Proper identification of S1 and S2 is the foundation of a comprehensive
cardiac assessment in nursing practice.
5. The nurse is assessing a patient for peripheral edema and finds a deep indentation that
remains for several seconds after pressure is released. How should this be graded?
A. 1+
B. 3+
C. 2+
D. 4+
Correct Answer: B
Explanation: A grade of 3+ edema is characterized by a deep pit (approx. 6mm) that
remains for a short time, and the leg looks swollen. Edema grading ranges from 1+ (mild)
to 4+ (very deep pit, lasts a long time). Nurses must use consistent terminology when
documenting these findings to track changes in a patient’s fluid status.
Q&A with Rationale | Fortis College
1. When performing an abdominal assessment, in which order should the nurse perform the
physical examination techniques?
A. Inspection, Palpation, Percussion, Auscultation
B. Inspection, Auscultation, Percussion, Palpation
C. Auscultation, Inspection, Palpation, Percussion
D. Percussion, Auscultation, Inspection, Palpation
Correct Answer: B
Explanation: The correct order for abdominal assessment is inspection, followed by
auscultation, percussion, and finally palpation. Auscultation is performed before
percussion and palpation because manual manipulation of the abdomen can stimulate
peristalsis and alter bowel sounds. This sequence is essential to ensure the nurse obtains
the most accurate clinical data regarding the patient’s bowel activity.
2. To assess the patient’s apical pulse, where should the nurse place the stethoscope?
A. Second intercostal space, right sternal border
B. Fifth intercostal space, left midclavicular line
C. Fourth intercostal space, left sternal border
D. Second intercostal space, left sternal border
,Correct Answer: B
Explanation: The apical pulse is best auscultated at the mitral area, located at the fifth
intercostal space at the left midclavicular line. This location represents the point of
maximal impulse where the left ventricle is closest to the chest wall. Locating this landmark
accurately is a critical skill for assessing heart rate and rhythm in the NUR 101 clinical
setting.
3. During a respiratory assessment, the nurse hears high-pitched, musical sounds primarily
during expiration. How should the nurse document this finding?
A. Crackles
B. Wheezes
C. Rhonchi
D. Pleural friction rub
Correct Answer: B
Explanation: Wheezes are continuous, high-pitched musical sounds caused by air flowing
through narrowed or obstructed airways. They are most commonly heard during
expiration but can also occur during inspiration. The nurse must distinguish these from
crackles, which are discontinuous popping sounds associated with fluid in the alveoli.
4. Which heart sound is produced by the closure of the atrioventricular (AV) valves?
A. S3
B. S2
, C. S1
D. S4
Correct Answer: C
Explanation: The S1 heart sound, often described as ‘lub,’ marks the beginning of systole
and is caused by the closure of the mitral and tricuspid valves. It is usually loudest at the
apex of the heart. Proper identification of S1 and S2 is the foundation of a comprehensive
cardiac assessment in nursing practice.
5. The nurse is assessing a patient for peripheral edema and finds a deep indentation that
remains for several seconds after pressure is released. How should this be graded?
A. 1+
B. 3+
C. 2+
D. 4+
Correct Answer: B
Explanation: A grade of 3+ edema is characterized by a deep pit (approx. 6mm) that
remains for a short time, and the leg looks swollen. Edema grading ranges from 1+ (mild)
to 4+ (very deep pit, lasts a long time). Nurses must use consistent terminology when
documenting these findings to track changes in a patient’s fluid status.
