NUR 216 EXAM 4 | COMPLETE QUESTIONS &
ANSWERS (100% VERIFIED SOLUTIONS)
2025/2026 UPDATE
Question 1
A nurse is preparing to assess a client's abdomen. Which of the following is
the correct order of assessment techniques?
A. Palpation, Percussion, Auscultation, Inspection
B. Inspection, Palpation, Percussion, Auscultation
C. Inspection, Auscultation, Percussion, Palpation
D. Auscultation, Inspection, Palpation, Percussion
*Correct Answer: C. Inspection, Auscultation, Percussion, Palpation. *
Rationale: The correct order for abdominal assessment is Inspection,
Auscultation, Percussion, then Palpation. Auscultation is performed before
percussion and palpation to avoid altering bowel sounds .
Question 2
A nurse is assessing a client's abdomen and notes a bulging area in the
midline when the client strains. This finding is consistent with:
A. Ascites
B. Diastasis recti
C. Hernia
D. Cullen's sign
*Correct Answer: B. Diastasis recti. *
,Rationale: Diastasis recti is a bulging area in the abdomen due to the
separation of the two halves of the rectus abdominis muscles in the midline
at the linea alba, often seen with straining .
Question 3
A client reports black, tarry stools. The nurse recognizes this finding as:
A. Melena
B. Hematochezia
C. Steatorrhea
D. Hematuria
*Correct Answer: A. Melena. *
Rationale: Melena is the passage of black, tarry, foul-smelling stools. This
indicates upper gastrointestinal bleeding, as the blood has been digested .
Question 4
When auscultating for bowel sounds, how long should the nurse listen
before documenting absence of bowel sounds?
A. 1 minute
B. 2 minutes
C. 3 minutes
D. 5 minutes
*Correct Answer: D. 5 minutes. *
Rationale: The nurse should listen for bowel sounds for a full 5 minutes in
each quadrant before documenting them as absent .
,Question 5
Which of the following findings is associated with ascites?
A. Hyperactive bowel sounds
B. Abdominal distention and shifting dullness
C. Cullen's sign
D. Visible peristalsis
*Correct Answer: B. Abdominal distention and shifting dullness. *
Rationale: Ascites is the accumulation of fluid in the peritoneal cavity, leading
to abdominal distention and shifting dullness on percussion. It is often
associated with jaundice and liver disease .
Question 6
The nurse notes ecchymosis (bruising) around the umbilicus. This finding is
documented as:
A. Grey-Turner's sign
B. Cullen's sign
C. McBurney's sign
D. Murphy's sign
*Correct Answer: B. Cullen's sign. *
Rationale: Cullen's sign is superficial bruising in the subcutaneous fat around
the umbilicus. It can indicate intra-abdominal bleeding, such as from a
ruptured ectopic pregnancy or pancreatitis .
Question 7
Which sound is heard throughout the abdomen during percussion?
, A. Dullness
B. Tympany
C. Flatness
D. Resonance
*Correct Answer: B. Tympany. *
Rationale: Tympany is a high-pitched, drum-like sound heard over air-filled
structures like the stomach and intestines. It is the dominant sound heard
over the normal abdomen .
Question 8
A firm, palpable bladder near the umbilicus indicates which of the
following?
A. Normal finding
B. Urinary retention
C. Bowel obstruction
D. Ascites
*Correct Answer: B. Urinary retention. *
Rationale: A palpable, firm bladder above the symphysis pubis indicates
urinary retention. The bladder must be significantly distended to be palpable
at or above the umbilicus .
Question 9
Which organ is located in the Right Upper Quadrant (RUQ)?
A. Stomach
B. Spleen
ANSWERS (100% VERIFIED SOLUTIONS)
2025/2026 UPDATE
Question 1
A nurse is preparing to assess a client's abdomen. Which of the following is
the correct order of assessment techniques?
A. Palpation, Percussion, Auscultation, Inspection
B. Inspection, Palpation, Percussion, Auscultation
C. Inspection, Auscultation, Percussion, Palpation
D. Auscultation, Inspection, Palpation, Percussion
*Correct Answer: C. Inspection, Auscultation, Percussion, Palpation. *
Rationale: The correct order for abdominal assessment is Inspection,
Auscultation, Percussion, then Palpation. Auscultation is performed before
percussion and palpation to avoid altering bowel sounds .
Question 2
A nurse is assessing a client's abdomen and notes a bulging area in the
midline when the client strains. This finding is consistent with:
A. Ascites
B. Diastasis recti
C. Hernia
D. Cullen's sign
*Correct Answer: B. Diastasis recti. *
,Rationale: Diastasis recti is a bulging area in the abdomen due to the
separation of the two halves of the rectus abdominis muscles in the midline
at the linea alba, often seen with straining .
Question 3
A client reports black, tarry stools. The nurse recognizes this finding as:
A. Melena
B. Hematochezia
C. Steatorrhea
D. Hematuria
*Correct Answer: A. Melena. *
Rationale: Melena is the passage of black, tarry, foul-smelling stools. This
indicates upper gastrointestinal bleeding, as the blood has been digested .
Question 4
When auscultating for bowel sounds, how long should the nurse listen
before documenting absence of bowel sounds?
A. 1 minute
B. 2 minutes
C. 3 minutes
D. 5 minutes
*Correct Answer: D. 5 minutes. *
Rationale: The nurse should listen for bowel sounds for a full 5 minutes in
each quadrant before documenting them as absent .
,Question 5
Which of the following findings is associated with ascites?
A. Hyperactive bowel sounds
B. Abdominal distention and shifting dullness
C. Cullen's sign
D. Visible peristalsis
*Correct Answer: B. Abdominal distention and shifting dullness. *
Rationale: Ascites is the accumulation of fluid in the peritoneal cavity, leading
to abdominal distention and shifting dullness on percussion. It is often
associated with jaundice and liver disease .
Question 6
The nurse notes ecchymosis (bruising) around the umbilicus. This finding is
documented as:
A. Grey-Turner's sign
B. Cullen's sign
C. McBurney's sign
D. Murphy's sign
*Correct Answer: B. Cullen's sign. *
Rationale: Cullen's sign is superficial bruising in the subcutaneous fat around
the umbilicus. It can indicate intra-abdominal bleeding, such as from a
ruptured ectopic pregnancy or pancreatitis .
Question 7
Which sound is heard throughout the abdomen during percussion?
, A. Dullness
B. Tympany
C. Flatness
D. Resonance
*Correct Answer: B. Tympany. *
Rationale: Tympany is a high-pitched, drum-like sound heard over air-filled
structures like the stomach and intestines. It is the dominant sound heard
over the normal abdomen .
Question 8
A firm, palpable bladder near the umbilicus indicates which of the
following?
A. Normal finding
B. Urinary retention
C. Bowel obstruction
D. Ascites
*Correct Answer: B. Urinary retention. *
Rationale: A palpable, firm bladder above the symphysis pubis indicates
urinary retention. The bladder must be significantly distended to be palpable
at or above the umbilicus .
Question 9
Which organ is located in the Right Upper Quadrant (RUQ)?
A. Stomach
B. Spleen
