,NSG 3160 Exam 4 | Health Assessment
(2026/2027) PDF | Nursing | Galen
1. When performing a comprehensive abdominal assessment, which sequence
should the nurse use to avoid altering bowel sounds?
A) Inspection, auscultation, percussion, palpation
B) Inspection, palpation, auscultation, percussion
C) Auscultation, inspection, percussion, palpation
D) Percussion, inspection, auscultation, palpation
Correct Answer: A) Inspection, auscultation, percussion, palpation
Rationale: The correct sequence is inspection, auscultation, percussion,
palpation. Auscultation must follow inspection because percussion and
palpation can stimulate bowel activity and alter sounds. This order prevents
false findings and is standard for abdominal assessment.
2. During an abdominal inspection, the nurse observes visible wavelike
movements across the client's abdomen. What does this finding most likely
indicate?
A) Normal peristalsis
B) Intestinal obstruction
C) Ascites
D) Organomegaly
Correct Answer: B) Intestinal obstruction
,Rationale: Visible peristaltic waves suggest increased peristalsis attempting to
overcome a blockage, often seen in intestinal obstruction. They are not normal
in adults. Ascites causes distention without visible waves, and organomegaly
presents as a mass.
3. The nurse is preparing to auscultate bowel sounds. Where should the
stethoscope be placed first?
A) Left lower quadrant
B) Right upper quadrant
C) Right lower quadrant
D) Left upper quadrant
Correct Answer: C) Right lower quadrant
Rationale: Bowel sounds are normally most active in the right lower quadrant
near the ileocecal valve. The nurse should begin there and proceed to all four
quadrants. This sequence helps capture normal peristaltic sounds.
4. To confirm absent bowel sounds, how long should the nurse listen in each
quadrant before documenting the finding?
A) 1 minute
B) 2 minutes
C) 3 minutes
D) 5 minutes
Correct Answer: D) 5 minutes
, Rationale: Absent bowel sounds are confirmed only after listening for a full 5
minutes per quadrant. Briefer listening may miss intermittent sounds.
Documenting absence requires this standard duration to be accurate.
5. A client reports tenderness in the right upper quadrant. Which structures
should the nurse consider as the source?
A) Liver, gallbladder, or duodenum
B) Stomach and spleen
C) Sigmoid colon and rectum
D) Appendix and cecum
Correct Answer: A) Liver, gallbladder, or duodenum
Rationale: The right upper quadrant contains the liver, gallbladder, duodenum,
and head of the pancreas. Tenderness here suggests hepatobiliary or duodenal
disease. The other options refer to left upper or lower quadrants.
6. While assessing a client's precordium, the nurse palpates a fine, palpable
vibration over the chest. Which term should the nurse use to document this
finding?
A) Bruit
B) Thrill
C) Murmur
D) Rub
(2026/2027) PDF | Nursing | Galen
1. When performing a comprehensive abdominal assessment, which sequence
should the nurse use to avoid altering bowel sounds?
A) Inspection, auscultation, percussion, palpation
B) Inspection, palpation, auscultation, percussion
C) Auscultation, inspection, percussion, palpation
D) Percussion, inspection, auscultation, palpation
Correct Answer: A) Inspection, auscultation, percussion, palpation
Rationale: The correct sequence is inspection, auscultation, percussion,
palpation. Auscultation must follow inspection because percussion and
palpation can stimulate bowel activity and alter sounds. This order prevents
false findings and is standard for abdominal assessment.
2. During an abdominal inspection, the nurse observes visible wavelike
movements across the client's abdomen. What does this finding most likely
indicate?
A) Normal peristalsis
B) Intestinal obstruction
C) Ascites
D) Organomegaly
Correct Answer: B) Intestinal obstruction
,Rationale: Visible peristaltic waves suggest increased peristalsis attempting to
overcome a blockage, often seen in intestinal obstruction. They are not normal
in adults. Ascites causes distention without visible waves, and organomegaly
presents as a mass.
3. The nurse is preparing to auscultate bowel sounds. Where should the
stethoscope be placed first?
A) Left lower quadrant
B) Right upper quadrant
C) Right lower quadrant
D) Left upper quadrant
Correct Answer: C) Right lower quadrant
Rationale: Bowel sounds are normally most active in the right lower quadrant
near the ileocecal valve. The nurse should begin there and proceed to all four
quadrants. This sequence helps capture normal peristaltic sounds.
4. To confirm absent bowel sounds, how long should the nurse listen in each
quadrant before documenting the finding?
A) 1 minute
B) 2 minutes
C) 3 minutes
D) 5 minutes
Correct Answer: D) 5 minutes
, Rationale: Absent bowel sounds are confirmed only after listening for a full 5
minutes per quadrant. Briefer listening may miss intermittent sounds.
Documenting absence requires this standard duration to be accurate.
5. A client reports tenderness in the right upper quadrant. Which structures
should the nurse consider as the source?
A) Liver, gallbladder, or duodenum
B) Stomach and spleen
C) Sigmoid colon and rectum
D) Appendix and cecum
Correct Answer: A) Liver, gallbladder, or duodenum
Rationale: The right upper quadrant contains the liver, gallbladder, duodenum,
and head of the pancreas. Tenderness here suggests hepatobiliary or duodenal
disease. The other options refer to left upper or lower quadrants.
6. While assessing a client's precordium, the nurse palpates a fine, palpable
vibration over the chest. Which term should the nurse use to document this
finding?
A) Bruit
B) Thrill
C) Murmur
D) Rub
