Nursing 111
Nursing 111 - Final Lab Exam Questions
and Answers 2025
Respirations at rest - Correct Ans-Ratio of 1 second inspiration to 2 seconds expiration
Respirations during exertion - Correct Ans-Ratio of 1 second inspiration to 1 second
expiration
Purposes of physical assessment - Correct Ans-Collect baseline data regarding the
patient's health status, validate, build on and/or refute historical data, reassessments
regarding patient's changing health status, evaluate outcomes of care and predict health
risks.
Criteria for an effective physical assessment - Correct Ans-Sufficient light, privacy,
quiet, patient comfort (warm, pain managed, toileting needs met), necessary equipment
available, minimal interruptions and infection control precautions
Items needed to perform a basic physical assessment - Correct Ans-Penlight, lubricant,
gloves, stethoscope, alcohol wipes, scissors, BP cuff, measuring device (side of gauze
packet?)
Techniques of physical assessment - Correct Ans-• Inspection - observations - try not to
look just at the obvious. Don't make assumptions & always to try get information from
the patient
• Palpation - using fingertips, palms or back of hand to make sensitive assessments like
temperature of skin, pain/tenderness, dry vs. damp skin, unusual lumps, swelling, pulse,
capillary refill
• Percussion - produces a vibration that travels through tissues - air filled organs make a
hollow, tympanic sound, dense or fluid filled organs make a dull sound
• Auscultation - listening to sounds the body makes, usually with a stethoscope -
clothing obscures the sound so place stethoscope directly on skin surface. Diaphragm
(flat) side is best for high pitch sounds like bowel, breath and normal heart sounds. Bell
side is best for low pitch sounds like extra heart sounds, murmurs.
Different assessment approaches - Correct Ans-Head to toe is a systematic approach
used in a doctor's office (for example) that includes all body systems starting at the
head and working down to the toes. A focused assessment includes more detail
regarding the area or system of concern if abnormalities are noted or suspected (like
focusing on a broken arm, for example). An emergency assessment is just that and
focuses initially on the ABC's (airway, breathing, circulation).
Developmental considerations for physical assessments - Correct Ans-For infants and
children - a head to toe assessment will usually not work because the patient won't sit
still. Ask the parents for information. Develop a rapport with the child to try to
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, Nursing 111
communicate with them and incorporate play into the assessment. Allow children to
touch or manipulate equipment. Encourage the child to talk about their fears or
concerns. Do not conduct painful procedures while the child is on the parent's lap as
children need to know they are safe from painful experiences when with their parent.
The nurse must determine the relationship between the child and caregiver to ensure
that the caregiver can legally consent to medical treatment. Use age appropriate
language when speaking with the child (i.e. tummy vs. abdomen). Explain procedures
and techniques in word that children can understand. Begin with the least threatening
part of the examination and end with the most painful or invasive procedure.
For adolescents - assessing adolescents with their parents and then one-on-one
provides a more complete picture and provides the patient an opportunity to express
themselves and discuss concerns more freely. Develop a rapport with the adolescent
and reassure that the changes happening to their bodies are normal.
Abnormal assessments which require immediate intervention - Correct Ans-Cyanosis,
anything that interferes with the ABC's, enlarged pupils >7mm
Wheals - Correct Ans-Hives or bites
Papule - Correct Ans-A raised lesion
Macule - Correct Ans-A flat lesion
Vesicle - Correct Ans-A raised lesion w/clear fluid or blood
Pustule - Correct Ans-A raised lesion with pus fluid
Macular-papular - Correct Ans-Raised & flat lesions together
To assess for pallor - Correct Ans-• Check gums, tongue, mucous membranes
• Eyelids or sclera (whites) of eyes
• Palms & nail beds
Brittle nails are a sign of... - Correct Ans-Poor nutrition
Clubbing of nails are a sign of... - Correct Ans-COPD or Cystic Fibrosis - chronic oxygen
deprivation
Vesicular breath sounds - Correct Ans-Everywhere in the respiratory system except
over the 2nd intercostal and the trachea; inspiration is longer than expiration
Bronchovesicular breath sounds - Correct Ans-Heard over the 2nd intercostal;
inspiration is the same length as expiration
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Nursing 111 - Final Lab Exam Questions
and Answers 2025
Respirations at rest - Correct Ans-Ratio of 1 second inspiration to 2 seconds expiration
Respirations during exertion - Correct Ans-Ratio of 1 second inspiration to 1 second
expiration
Purposes of physical assessment - Correct Ans-Collect baseline data regarding the
patient's health status, validate, build on and/or refute historical data, reassessments
regarding patient's changing health status, evaluate outcomes of care and predict health
risks.
Criteria for an effective physical assessment - Correct Ans-Sufficient light, privacy,
quiet, patient comfort (warm, pain managed, toileting needs met), necessary equipment
available, minimal interruptions and infection control precautions
Items needed to perform a basic physical assessment - Correct Ans-Penlight, lubricant,
gloves, stethoscope, alcohol wipes, scissors, BP cuff, measuring device (side of gauze
packet?)
Techniques of physical assessment - Correct Ans-• Inspection - observations - try not to
look just at the obvious. Don't make assumptions & always to try get information from
the patient
• Palpation - using fingertips, palms or back of hand to make sensitive assessments like
temperature of skin, pain/tenderness, dry vs. damp skin, unusual lumps, swelling, pulse,
capillary refill
• Percussion - produces a vibration that travels through tissues - air filled organs make a
hollow, tympanic sound, dense or fluid filled organs make a dull sound
• Auscultation - listening to sounds the body makes, usually with a stethoscope -
clothing obscures the sound so place stethoscope directly on skin surface. Diaphragm
(flat) side is best for high pitch sounds like bowel, breath and normal heart sounds. Bell
side is best for low pitch sounds like extra heart sounds, murmurs.
Different assessment approaches - Correct Ans-Head to toe is a systematic approach
used in a doctor's office (for example) that includes all body systems starting at the
head and working down to the toes. A focused assessment includes more detail
regarding the area or system of concern if abnormalities are noted or suspected (like
focusing on a broken arm, for example). An emergency assessment is just that and
focuses initially on the ABC's (airway, breathing, circulation).
Developmental considerations for physical assessments - Correct Ans-For infants and
children - a head to toe assessment will usually not work because the patient won't sit
still. Ask the parents for information. Develop a rapport with the child to try to
1|Page
, Nursing 111
communicate with them and incorporate play into the assessment. Allow children to
touch or manipulate equipment. Encourage the child to talk about their fears or
concerns. Do not conduct painful procedures while the child is on the parent's lap as
children need to know they are safe from painful experiences when with their parent.
The nurse must determine the relationship between the child and caregiver to ensure
that the caregiver can legally consent to medical treatment. Use age appropriate
language when speaking with the child (i.e. tummy vs. abdomen). Explain procedures
and techniques in word that children can understand. Begin with the least threatening
part of the examination and end with the most painful or invasive procedure.
For adolescents - assessing adolescents with their parents and then one-on-one
provides a more complete picture and provides the patient an opportunity to express
themselves and discuss concerns more freely. Develop a rapport with the adolescent
and reassure that the changes happening to their bodies are normal.
Abnormal assessments which require immediate intervention - Correct Ans-Cyanosis,
anything that interferes with the ABC's, enlarged pupils >7mm
Wheals - Correct Ans-Hives or bites
Papule - Correct Ans-A raised lesion
Macule - Correct Ans-A flat lesion
Vesicle - Correct Ans-A raised lesion w/clear fluid or blood
Pustule - Correct Ans-A raised lesion with pus fluid
Macular-papular - Correct Ans-Raised & flat lesions together
To assess for pallor - Correct Ans-• Check gums, tongue, mucous membranes
• Eyelids or sclera (whites) of eyes
• Palms & nail beds
Brittle nails are a sign of... - Correct Ans-Poor nutrition
Clubbing of nails are a sign of... - Correct Ans-COPD or Cystic Fibrosis - chronic oxygen
deprivation
Vesicular breath sounds - Correct Ans-Everywhere in the respiratory system except
over the 2nd intercostal and the trachea; inspiration is longer than expiration
Bronchovesicular breath sounds - Correct Ans-Heard over the 2nd intercostal;
inspiration is the same length as expiration
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