NUR 101/NUR101 Final Exam V2 | Health
Assessment Q&A with Rationale | Fortis
College
1. When conducting a physical examination of the abdomen, in which order should the nurse
perform the assessment techniques?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Palpation, Percussion, Auscultation
C. Auscultation, Inspection, Palpation, Percussion
D. Percussion, Auscultation, Palpation, Inspection
Correct Answer: A
Expert Explanation: The abdominal assessment sequence is unique because palpation and
percussion can stimulate bowel activity and change the frequency of bowel sounds. By
auscultating immediately after inspection, the nurse ensures the sounds heard are a true
reflection of the patient’s baseline gastrointestinal status. This standard of practice is a
fundamental component of the NUR 101 curriculum regarding physical examination safety
and accuracy.
2. A nurse is assessing a patient’s radial pulse and notes that it is irregular. What is the
priority nursing action?
A. Document the finding and reassess in four hours
,B. Assess the carotid pulse instead
C. Check the pulse for a full 60 seconds
D. Notify the physician immediately
Correct Answer: C
Expert Explanation: If a peripheral pulse is irregular, the nurse must count the rate for a
full minute to obtain the most accurate measurement. This allows the nurse to identify the
specific pattern of irregularity and any skipped beats. Following this, the nurse should also
perform an apical-radial pulse comparison to check for a pulse deficit.
3. Which component of the nursing process involves the systematic collection of subjective
and objective data?
A. Assessment
B. Planning
C. Implementation
D. Evaluation
Correct Answer: A
Expert Explanation: Assessment is the foundational first step of the nursing process
where the clinician gathers all necessary information to identify patient needs. It includes
both the health history (subjective) and the physical examination (objective). Without a
, thorough assessment, the subsequent steps of diagnosis and planning cannot be accurately
performed.
4. A patient reports ‘crushing chest pain’ that radiates to the left arm. This report is
categorized as which type of data?
A. Subjective data
B. Secondary data
C. Objective data
D. Analytical data
Correct Answer: A
Expert Explanation: Subjective data refers to what the patient says, including their
feelings, perceptions, and self-reported symptoms. Because the nurse cannot directly see or
measure the ‘crushing’ sensation, it relies entirely on the patient’s testimony. Objective
data, by contrast, would be measurable signs like blood pressure or an EKG reading.
5. While assessing a patient’s skin, the nurse notes a 4mm deep indentation after pressing the
skin that takes several seconds to return to normal. How should this be documented?
A. 1+ Edema
B. 3+ Edema
C. 2+ Edema
D. 4+ Edema
Assessment Q&A with Rationale | Fortis
College
1. When conducting a physical examination of the abdomen, in which order should the nurse
perform the assessment techniques?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Palpation, Percussion, Auscultation
C. Auscultation, Inspection, Palpation, Percussion
D. Percussion, Auscultation, Palpation, Inspection
Correct Answer: A
Expert Explanation: The abdominal assessment sequence is unique because palpation and
percussion can stimulate bowel activity and change the frequency of bowel sounds. By
auscultating immediately after inspection, the nurse ensures the sounds heard are a true
reflection of the patient’s baseline gastrointestinal status. This standard of practice is a
fundamental component of the NUR 101 curriculum regarding physical examination safety
and accuracy.
2. A nurse is assessing a patient’s radial pulse and notes that it is irregular. What is the
priority nursing action?
A. Document the finding and reassess in four hours
,B. Assess the carotid pulse instead
C. Check the pulse for a full 60 seconds
D. Notify the physician immediately
Correct Answer: C
Expert Explanation: If a peripheral pulse is irregular, the nurse must count the rate for a
full minute to obtain the most accurate measurement. This allows the nurse to identify the
specific pattern of irregularity and any skipped beats. Following this, the nurse should also
perform an apical-radial pulse comparison to check for a pulse deficit.
3. Which component of the nursing process involves the systematic collection of subjective
and objective data?
A. Assessment
B. Planning
C. Implementation
D. Evaluation
Correct Answer: A
Expert Explanation: Assessment is the foundational first step of the nursing process
where the clinician gathers all necessary information to identify patient needs. It includes
both the health history (subjective) and the physical examination (objective). Without a
, thorough assessment, the subsequent steps of diagnosis and planning cannot be accurately
performed.
4. A patient reports ‘crushing chest pain’ that radiates to the left arm. This report is
categorized as which type of data?
A. Subjective data
B. Secondary data
C. Objective data
D. Analytical data
Correct Answer: A
Expert Explanation: Subjective data refers to what the patient says, including their
feelings, perceptions, and self-reported symptoms. Because the nurse cannot directly see or
measure the ‘crushing’ sensation, it relies entirely on the patient’s testimony. Objective
data, by contrast, would be measurable signs like blood pressure or an EKG reading.
5. While assessing a patient’s skin, the nurse notes a 4mm deep indentation after pressing the
skin that takes several seconds to return to normal. How should this be documented?
A. 1+ Edema
B. 3+ Edema
C. 2+ Edema
D. 4+ Edema
