NR 224 – Fundamentals of Nursing: Health Assessment
100 NCLEX-Style Practice Questions with Detailed Rationales
1. A nurse is preparing to perform a comprehensive physical assessment on a newly admitted
patient. Which action should the nurse perform first?
A. Begin the head-to-toe examination.
B. Review the patient's laboratory results.
C. Introduce themselves, verify the patient's identity, and explain the procedure.
D. Obtain the patient's vital signs.
Answer: C. Introduce themselves, verify the patient's identity, and explain the procedure.
Rationale: Establishing rapport, verifying the patient's identity using two identifiers,
and explaining the assessment promote patient safety, reduce anxiety, and obtain
informed cooperation before beginning the examination.
2. During a physical assessment, which technique should the nurse use first?
A. Palpation.
B. Inspection.
C. Percussion.
D. Auscultation.
Answer: B. Inspection.
Rationale: Inspection is the first step of the physical examination and involves
careful visual observation of the patient's appearance, movement, symmetry, and
behavior before touching the patient.
3. A nurse is assessing a patient's abdomen. Which sequence should the nurse follow?
A. Inspection, auscultation, percussion, palpation.
B. Inspection, palpation, percussion, auscultation.
C. Auscultation, inspection, palpation, percussion.
D. Palpation, percussion, inspection, auscultation.
,Answer: A. Inspection, auscultation, percussion, palpation.
Rationale: The abdominal assessment is unique because auscultation is performed
before percussion and palpation to avoid altering bowel sounds.
4. Which assessment finding should the nurse report immediately?
A. Capillary refill of less than 2 seconds.
B. Bilateral pupils equal, round, and reactive to light.
C. New onset of unilateral facial drooping.
D. Warm, dry skin.
Answer: C. New onset of unilateral facial drooping.
Rationale: Sudden facial drooping may indicate an acute stroke and requires
immediate assessment and intervention using emergency protocols.
5. A nurse is assessing a patient's level of consciousness. Which question best evaluates
orientation to person?
A. "What year is it?"
B. "Can you tell me your full name?"
C. "Where are you right now?"
D. "Why are you in the hospital?"
Answer: B. "Can you tell me your full name?"
Rationale: Orientation to person is assessed by determining whether the patient
correctly identifies themselves.
6. A nurse is assessing a patient's pupils. Which documentation indicates an expected finding?
A. Pupils unequal and fixed.
B. PERRLA.
C. Pupils sluggish and unequal.
D. Pinpoint pupils bilaterally.
Answer: B. PERRLA.
,Rationale: PERRLA means the pupils are Equal, Round, Reactive to Light, and
Accommodating, which is an expected assessment finding in most adults.
7. A nurse is palpating a patient's abdomen. Which action is appropriate?
A. Begin with deep palpation over the painful area.
B. Warm the hands before palpation.
C. Use rapid, firm pressure throughout the examination.
D. Ask the patient to sit upright during palpation.
Answer: B. Warm the hands before palpation.
Rationale: Warm hands help promote patient comfort and reduce muscle guarding
during palpation.
8. Which assessment finding requires immediate follow-up?
A. Skin warm and intact.
B. Respiratory rate of 18 breaths/min.
C. Absent bowel sounds in all four quadrants after 5 minutes of auscultation.
D. Heart rate of 78 beats/min.
Answer: C. Absent bowel sounds in all four quadrants after 5 minutes of auscultation.
Rationale: Absent bowel sounds after adequate assessment may indicate an ileus or
bowel obstruction and require prompt evaluation.
9. A nurse is assessing a patient's skin. Which finding is most concerning?
A. Even skin pigmentation.
B. Moist mucous membranes.
C. Non-blanchable redness over the sacrum.
D. Warm skin temperature.
Answer: C. Non-blanchable redness over the sacrum.
Rationale: Non-blanchable erythema over a bony prominence is consistent with a
Stage 1 pressure injury and requires immediate intervention to prevent further
skin breakdown.
, 10. Which assessment technique involves using the sense of touch?
A. Inspection.
B. Palpation.
C. Percussion.
D. Auscultation.
Answer: B. Palpation.
Rationale: Palpation uses the hands to assess temperature, tenderness, texture,
moisture, masses, and organ size.
11. A nurse is assessing capillary refill. Which finding is expected?
A. Greater than 5 seconds.
B. Less than 2 seconds.
C. Exactly 4 seconds.
D. No visible color return.
Answer: B. Less than 2 seconds.
Rationale: Capillary refill should normally return within 2 seconds, indicating
adequate peripheral perfusion.
12. A nurse observes that a patient becomes short of breath while speaking in full sentences.
What should the nurse do first?
A. Continue the assessment.
B. Assess the patient's airway and breathing.
C. Document the finding after the examination.
D. Ask the patient to finish answering the questions.
Answer: B. Assess the patient's airway and breathing.
Rationale: Using the ABC framework, any sign of respiratory distress requires
immediate assessment before continuing the physical examination.
13. A nurse is auscultating lung sounds. Which finding is expected in healthy lungs?
100 NCLEX-Style Practice Questions with Detailed Rationales
1. A nurse is preparing to perform a comprehensive physical assessment on a newly admitted
patient. Which action should the nurse perform first?
A. Begin the head-to-toe examination.
B. Review the patient's laboratory results.
C. Introduce themselves, verify the patient's identity, and explain the procedure.
D. Obtain the patient's vital signs.
Answer: C. Introduce themselves, verify the patient's identity, and explain the procedure.
Rationale: Establishing rapport, verifying the patient's identity using two identifiers,
and explaining the assessment promote patient safety, reduce anxiety, and obtain
informed cooperation before beginning the examination.
2. During a physical assessment, which technique should the nurse use first?
A. Palpation.
B. Inspection.
C. Percussion.
D. Auscultation.
Answer: B. Inspection.
Rationale: Inspection is the first step of the physical examination and involves
careful visual observation of the patient's appearance, movement, symmetry, and
behavior before touching the patient.
3. A nurse is assessing a patient's abdomen. Which sequence should the nurse follow?
A. Inspection, auscultation, percussion, palpation.
B. Inspection, palpation, percussion, auscultation.
C. Auscultation, inspection, palpation, percussion.
D. Palpation, percussion, inspection, auscultation.
,Answer: A. Inspection, auscultation, percussion, palpation.
Rationale: The abdominal assessment is unique because auscultation is performed
before percussion and palpation to avoid altering bowel sounds.
4. Which assessment finding should the nurse report immediately?
A. Capillary refill of less than 2 seconds.
B. Bilateral pupils equal, round, and reactive to light.
C. New onset of unilateral facial drooping.
D. Warm, dry skin.
Answer: C. New onset of unilateral facial drooping.
Rationale: Sudden facial drooping may indicate an acute stroke and requires
immediate assessment and intervention using emergency protocols.
5. A nurse is assessing a patient's level of consciousness. Which question best evaluates
orientation to person?
A. "What year is it?"
B. "Can you tell me your full name?"
C. "Where are you right now?"
D. "Why are you in the hospital?"
Answer: B. "Can you tell me your full name?"
Rationale: Orientation to person is assessed by determining whether the patient
correctly identifies themselves.
6. A nurse is assessing a patient's pupils. Which documentation indicates an expected finding?
A. Pupils unequal and fixed.
B. PERRLA.
C. Pupils sluggish and unequal.
D. Pinpoint pupils bilaterally.
Answer: B. PERRLA.
,Rationale: PERRLA means the pupils are Equal, Round, Reactive to Light, and
Accommodating, which is an expected assessment finding in most adults.
7. A nurse is palpating a patient's abdomen. Which action is appropriate?
A. Begin with deep palpation over the painful area.
B. Warm the hands before palpation.
C. Use rapid, firm pressure throughout the examination.
D. Ask the patient to sit upright during palpation.
Answer: B. Warm the hands before palpation.
Rationale: Warm hands help promote patient comfort and reduce muscle guarding
during palpation.
8. Which assessment finding requires immediate follow-up?
A. Skin warm and intact.
B. Respiratory rate of 18 breaths/min.
C. Absent bowel sounds in all four quadrants after 5 minutes of auscultation.
D. Heart rate of 78 beats/min.
Answer: C. Absent bowel sounds in all four quadrants after 5 minutes of auscultation.
Rationale: Absent bowel sounds after adequate assessment may indicate an ileus or
bowel obstruction and require prompt evaluation.
9. A nurse is assessing a patient's skin. Which finding is most concerning?
A. Even skin pigmentation.
B. Moist mucous membranes.
C. Non-blanchable redness over the sacrum.
D. Warm skin temperature.
Answer: C. Non-blanchable redness over the sacrum.
Rationale: Non-blanchable erythema over a bony prominence is consistent with a
Stage 1 pressure injury and requires immediate intervention to prevent further
skin breakdown.
, 10. Which assessment technique involves using the sense of touch?
A. Inspection.
B. Palpation.
C. Percussion.
D. Auscultation.
Answer: B. Palpation.
Rationale: Palpation uses the hands to assess temperature, tenderness, texture,
moisture, masses, and organ size.
11. A nurse is assessing capillary refill. Which finding is expected?
A. Greater than 5 seconds.
B. Less than 2 seconds.
C. Exactly 4 seconds.
D. No visible color return.
Answer: B. Less than 2 seconds.
Rationale: Capillary refill should normally return within 2 seconds, indicating
adequate peripheral perfusion.
12. A nurse observes that a patient becomes short of breath while speaking in full sentences.
What should the nurse do first?
A. Continue the assessment.
B. Assess the patient's airway and breathing.
C. Document the finding after the examination.
D. Ask the patient to finish answering the questions.
Answer: B. Assess the patient's airway and breathing.
Rationale: Using the ABC framework, any sign of respiratory distress requires
immediate assessment before continuing the physical examination.
13. A nurse is auscultating lung sounds. Which finding is expected in healthy lungs?
