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NSG 3160 Exam 4 — Health Assessment
Questions With Verified Solutions And
Rationales
1. Which of the following is the correct sequence of techniques for an abdominal
assessment?
A. Inspection, palpation, percussion, auscultation
B. Auscultation, inspection, palpation, percussion
C. Inspection, auscultation, percussion, palpation
D. Palpation, percussion, inspection, auscultation
Correct Answer: C
Rationale: The abdominal assessment sequence is inspection, auscultation,
percussion, and palpation. This modified order prevents palpation and percussion
from altering bowel sounds before auscultation .
2. A nurse is auscultating a patient's abdomen and notes bowel sounds that are
high-pitched, gurgling, and occur approximately 5 to 30 times per minute. How
should this finding be documented?
A. Hypoactive bowel sounds
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B. Normoactive bowel sounds
C. Hyperactive bowel sounds
D. Absent bowel sounds
Correct Answer: B
Rationale: Normoactive bowel sounds are characterized by high-pitched, gurgling,
cascading sounds occurring 5 to 30 times per minute. Hypoactive sounds are
fewer than 5 per minute, hyperactive sounds are greater than 30 per minute, and
absent bowel sounds require listening for 5 minutes per quadrant .
3. During an abdominal inspection, the nurse observes visible, wavelike
movements across the patient's abdomen. This finding is most consistent with
which condition?
A. Normal peristalsis
B. Intestinal obstruction
C. Ascites
D. Organomegaly
Correct Answer: B
Rationale: Visible peristaltic waves suggest increased peristalsis attempting to
overcome a blockage, which is often seen in intestinal obstruction. These waves
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are not a normal finding in adults. Ascites presents with a distended, taut
abdomen, and organomegaly would not produce visible peristaltic waves .
4. When assessing a patient for possible absent bowel sounds, how long should
the nurse listen in each quadrant before documenting absence?
A. 1 minute
B. 2 minutes
C. 3 minutes
D. 5 minutes
Correct Answer: D
Rationale: To confirm absent bowel sounds, the nurse must listen for a full 5
minutes in each quadrant. Briefer listening periods may miss intermittent sounds
and result in an inaccurate assessment of a silent abdomen .
5. The nurse is preparing to percuss the abdomen and hears a loud, drum-like
sound over most of the area. How should the nurse document this finding?
A. Flatness
B. Dullness
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C. Resonance
D. Tympany
Correct Answer: D
Rationale: Tympany is the predominant sound heard over the abdomen due to
the presence of air in the stomach and intestines. Dullness is heard over solid
organs such as the liver, resonance is heard over normal lung tissue, and flatness
is heard over bone or muscle .
6. Which organ is located in the right upper quadrant of the abdomen?
A. Spleen
B. Sigmoid colon
C. Appendix
D. Liver
Correct Answer: D
Rationale: The liver occupies most of the right upper quadrant (RUQ). The spleen
is located in the left upper quadrant, the sigmoid colon in the left lower quadrant,
and the appendix in the right lower quadrant .
NSG 3160 Exam 4 — Health Assessment
Questions With Verified Solutions And
Rationales
1. Which of the following is the correct sequence of techniques for an abdominal
assessment?
A. Inspection, palpation, percussion, auscultation
B. Auscultation, inspection, palpation, percussion
C. Inspection, auscultation, percussion, palpation
D. Palpation, percussion, inspection, auscultation
Correct Answer: C
Rationale: The abdominal assessment sequence is inspection, auscultation,
percussion, and palpation. This modified order prevents palpation and percussion
from altering bowel sounds before auscultation .
2. A nurse is auscultating a patient's abdomen and notes bowel sounds that are
high-pitched, gurgling, and occur approximately 5 to 30 times per minute. How
should this finding be documented?
A. Hypoactive bowel sounds
,2|Page
B. Normoactive bowel sounds
C. Hyperactive bowel sounds
D. Absent bowel sounds
Correct Answer: B
Rationale: Normoactive bowel sounds are characterized by high-pitched, gurgling,
cascading sounds occurring 5 to 30 times per minute. Hypoactive sounds are
fewer than 5 per minute, hyperactive sounds are greater than 30 per minute, and
absent bowel sounds require listening for 5 minutes per quadrant .
3. During an abdominal inspection, the nurse observes visible, wavelike
movements across the patient's abdomen. This finding is most consistent with
which condition?
A. Normal peristalsis
B. Intestinal obstruction
C. Ascites
D. Organomegaly
Correct Answer: B
Rationale: Visible peristaltic waves suggest increased peristalsis attempting to
overcome a blockage, which is often seen in intestinal obstruction. These waves
,3|Page
are not a normal finding in adults. Ascites presents with a distended, taut
abdomen, and organomegaly would not produce visible peristaltic waves .
4. When assessing a patient for possible absent bowel sounds, how long should
the nurse listen in each quadrant before documenting absence?
A. 1 minute
B. 2 minutes
C. 3 minutes
D. 5 minutes
Correct Answer: D
Rationale: To confirm absent bowel sounds, the nurse must listen for a full 5
minutes in each quadrant. Briefer listening periods may miss intermittent sounds
and result in an inaccurate assessment of a silent abdomen .
5. The nurse is preparing to percuss the abdomen and hears a loud, drum-like
sound over most of the area. How should the nurse document this finding?
A. Flatness
B. Dullness
, 4|Page
C. Resonance
D. Tympany
Correct Answer: D
Rationale: Tympany is the predominant sound heard over the abdomen due to
the presence of air in the stomach and intestines. Dullness is heard over solid
organs such as the liver, resonance is heard over normal lung tissue, and flatness
is heard over bone or muscle .
6. Which organ is located in the right upper quadrant of the abdomen?
A. Spleen
B. Sigmoid colon
C. Appendix
D. Liver
Correct Answer: D
Rationale: The liver occupies most of the right upper quadrant (RUQ). The spleen
is located in the left upper quadrant, the sigmoid colon in the left lower quadrant,
and the appendix in the right lower quadrant .
