NURS 100
NURS 100 Assessment 2 WCU |Exam Questions
with Detailed Answers| 2026
Objective data can be gathered from the patient during which aspects of the
physical assessment process? (Select all that apply.)
a. Patient interview
b. Health history
c. General survey
d. Physical examination
e. Laboratory testing
Which sequence best identifies the order in which the nurse should complete an
abdominal assessment?
a. Inspection, palpation, percussion, auscultation
b. Auscultation, inspection, palpation, percussion
c. Auscultation, palpation, percussion, inspection
d. Inspection, auscultation, percussion, palpation
d. Inspection, auscultation, percussion, palpation
A nurse is preparing to auscultate a patient's chest. In which area should the nurse
listen to evaluate the patient's aortic valve?
a. Second right intercostal space
b. Third left intercostal space
c. Fifth right intercostal space
d. Fifth left intercostal space along the midclavicular line
a. Second right intercostal space
The nurse notes the presence of ptosis when assessing an adult patient's eyes.
Which potential cause would be considered of most concern, requiring further
evaluation as soon as possible?
a. Loss of skin elasticity
b. Levator muscle weakness
NURS 100
,NURS 100
c. Congenital ocular abnormality
d. Oculomotor cranial nerve III paralysis
d. Oculomotor cranial nerve III paralysis
Which type of lung sounds does the nurse expect to auscultate over most of the
lung fields?
a. Vesicular
b. Resonant
c. Dull
d. Flat
a. Vesicular
When teaching a patient about fire safety, which activity does the nurse know is
the leading cause of fire-related death?
a. Cooking
b. Playing with matches
c. Smoking
d. Heating with kerosene heaters
a. Cooking
Cooking I the leading cause of residential fires for the last decade, followed by
heating, electrical malfunction. And other unintentional causes or carelessness.
Which measures can the nurse teach to prevent poisoning of children? (Select all
that apply.)
a. Install safety latches on reachable cabinets.
b. Keep syrup of ipecac on hand.
c. Use childproof caps on medications.
d. Use a plunger rather than a chemical drain cleaner.
e. Keep cleaning supplies under the kitchen sink.
a. Install safety latches on reachable cabinets.
c. Use childproof caps on medications.
d. Use a plunger rather than a chemical drain cleaner.
NURS 100
,NURS 100
Child locks for cabinet and childproof caps for medication bottles are
recommended to prevent poisoning. The use of alternatives (e.g. plungers) rather
than toxic chemicals. (e.g. Drano) is recommended to prevent ingestion of deadly
substances. Syrup of ipecac has been used in the past to treat poisoning after it
occurred and is not considered a preventive measure. Keeping cleaning supplies
under the kitchen sink is dangerous because the area is within reach o children.
Which restraint-free alternative is best for the nurse to use for an 84-year-old
patient after hip replacement who has confusion and incontinence?
a. A room near the nurses' station and decreased sensory stimuli
b. A pressure sensor alarm and a room near the nurses' station
c. Side rails up and decreased sensory stimuli
d. A 24-hour sitter and the patient's favorite TV program
b. A pressure sensor alarm and a room near the nurses' station
Patients with confusion may not remember to call for assistance before getting up,
especially if they have had an episode of incontinence. A pressure sensor alarm
that can be used in a bed or chair should be implemented as a priority
intervention along with moving the patient to a room near the nurses station,
where the patient be more closely monitored. Although decreasing sensory
stimuli may help patient with confusion, it is not a priority intervention. A 24-hour
sitter is costly and used only after all other restraint-free alternative are
exhausted.
Which activity would be most appropriate for the registered nurse (RN) to
delegate to unlicensed assistive personnel (UAP)?
a. Assessing the patient for fall risk and complications of restraint use
b. Evaluating the patient's ability to perform activities of daily living (ADLs)
c. Assisting with or performing the patient's ADLs
d. Teaching the patient use of assistive devices
c. Assisting with or performing the patient's ADLs
UAP such as patient care technicians and nursing assistants, provide hands-on
care for patients who may require complete care or total assistance with their
activities of daily living (ADL's). However, RN's are responsible for supervising and
guiding the UAP so direct care is provided in a safe manner. RNs are responsible
for performing patient assessments, and the OT evaluates the patients ability to
NURS 100
, NURS 100
perform ADL's. A physical therapist evaluates mobility and initially teaches the
patient to use an assistive device. If use assistive device needs reinforcement, the
RN does the teaching.
Which patient appears to be at greatest risk for falls?
a. 66 year old post-op, oriented x 3, taking opioid pain meds
b. 71 year old with pneumonia, oriented x 2, on oxygen and IV
c. 76 year old with acute confusion, knows name, incontinent, has an IV
d. 80 year old post-op, oriented x 3, has a cast, opioid pain medications
c. 76 year old with acute confusion, knows name, incontinent, has an IV
The 76 year old with acute confusion and incontinence with a continuous IV
appears to be at greatest risk for falls. While the other patients also have sources
of tethering (e.g., oxygen and IV tubing) and opioid pain medications, the acute
confusion and incontinence along with the IV tethering produce the most
significant risk.
An ambulatory diabetic patient states that she is unable to reach her feet to clip
her toenails. The patient's toenails are long and thick. What is the next step the
nurse should take?
a. Soak the patient's feet, and trim her toenails using clippers.
b. Delegate foot care of this patient to the unlicensed assistive personnel (UAP).
c. Assess the patient's self-care abilities.
d. Ask the primary care provider (PCP) for a referral to a podiatrist.
d. Ask the primary care provider (PCP) for a referral to a podiatrist.
Referral to Podiatrist is appropriate when the diabetic patient is unable to care for
her feet. Soaking is contraindicated for patients with diabetes due to the risk for
skin breakdown. Clippers are not appropriate if nails are thick. Delegating of nail
care to the UAP is inappropriate for patients with peripheral neuropathy. The
nurse already knows the patient's self-care status abilities in regard to her feet.
Which action by a female patient lets the nurse know the patient has understood
perineal care teaching?
a. The patient washes her perineum with a circular motion beginning at the
NURS 100
NURS 100 Assessment 2 WCU |Exam Questions
with Detailed Answers| 2026
Objective data can be gathered from the patient during which aspects of the
physical assessment process? (Select all that apply.)
a. Patient interview
b. Health history
c. General survey
d. Physical examination
e. Laboratory testing
Which sequence best identifies the order in which the nurse should complete an
abdominal assessment?
a. Inspection, palpation, percussion, auscultation
b. Auscultation, inspection, palpation, percussion
c. Auscultation, palpation, percussion, inspection
d. Inspection, auscultation, percussion, palpation
d. Inspection, auscultation, percussion, palpation
A nurse is preparing to auscultate a patient's chest. In which area should the nurse
listen to evaluate the patient's aortic valve?
a. Second right intercostal space
b. Third left intercostal space
c. Fifth right intercostal space
d. Fifth left intercostal space along the midclavicular line
a. Second right intercostal space
The nurse notes the presence of ptosis when assessing an adult patient's eyes.
Which potential cause would be considered of most concern, requiring further
evaluation as soon as possible?
a. Loss of skin elasticity
b. Levator muscle weakness
NURS 100
,NURS 100
c. Congenital ocular abnormality
d. Oculomotor cranial nerve III paralysis
d. Oculomotor cranial nerve III paralysis
Which type of lung sounds does the nurse expect to auscultate over most of the
lung fields?
a. Vesicular
b. Resonant
c. Dull
d. Flat
a. Vesicular
When teaching a patient about fire safety, which activity does the nurse know is
the leading cause of fire-related death?
a. Cooking
b. Playing with matches
c. Smoking
d. Heating with kerosene heaters
a. Cooking
Cooking I the leading cause of residential fires for the last decade, followed by
heating, electrical malfunction. And other unintentional causes or carelessness.
Which measures can the nurse teach to prevent poisoning of children? (Select all
that apply.)
a. Install safety latches on reachable cabinets.
b. Keep syrup of ipecac on hand.
c. Use childproof caps on medications.
d. Use a plunger rather than a chemical drain cleaner.
e. Keep cleaning supplies under the kitchen sink.
a. Install safety latches on reachable cabinets.
c. Use childproof caps on medications.
d. Use a plunger rather than a chemical drain cleaner.
NURS 100
,NURS 100
Child locks for cabinet and childproof caps for medication bottles are
recommended to prevent poisoning. The use of alternatives (e.g. plungers) rather
than toxic chemicals. (e.g. Drano) is recommended to prevent ingestion of deadly
substances. Syrup of ipecac has been used in the past to treat poisoning after it
occurred and is not considered a preventive measure. Keeping cleaning supplies
under the kitchen sink is dangerous because the area is within reach o children.
Which restraint-free alternative is best for the nurse to use for an 84-year-old
patient after hip replacement who has confusion and incontinence?
a. A room near the nurses' station and decreased sensory stimuli
b. A pressure sensor alarm and a room near the nurses' station
c. Side rails up and decreased sensory stimuli
d. A 24-hour sitter and the patient's favorite TV program
b. A pressure sensor alarm and a room near the nurses' station
Patients with confusion may not remember to call for assistance before getting up,
especially if they have had an episode of incontinence. A pressure sensor alarm
that can be used in a bed or chair should be implemented as a priority
intervention along with moving the patient to a room near the nurses station,
where the patient be more closely monitored. Although decreasing sensory
stimuli may help patient with confusion, it is not a priority intervention. A 24-hour
sitter is costly and used only after all other restraint-free alternative are
exhausted.
Which activity would be most appropriate for the registered nurse (RN) to
delegate to unlicensed assistive personnel (UAP)?
a. Assessing the patient for fall risk and complications of restraint use
b. Evaluating the patient's ability to perform activities of daily living (ADLs)
c. Assisting with or performing the patient's ADLs
d. Teaching the patient use of assistive devices
c. Assisting with or performing the patient's ADLs
UAP such as patient care technicians and nursing assistants, provide hands-on
care for patients who may require complete care or total assistance with their
activities of daily living (ADL's). However, RN's are responsible for supervising and
guiding the UAP so direct care is provided in a safe manner. RNs are responsible
for performing patient assessments, and the OT evaluates the patients ability to
NURS 100
, NURS 100
perform ADL's. A physical therapist evaluates mobility and initially teaches the
patient to use an assistive device. If use assistive device needs reinforcement, the
RN does the teaching.
Which patient appears to be at greatest risk for falls?
a. 66 year old post-op, oriented x 3, taking opioid pain meds
b. 71 year old with pneumonia, oriented x 2, on oxygen and IV
c. 76 year old with acute confusion, knows name, incontinent, has an IV
d. 80 year old post-op, oriented x 3, has a cast, opioid pain medications
c. 76 year old with acute confusion, knows name, incontinent, has an IV
The 76 year old with acute confusion and incontinence with a continuous IV
appears to be at greatest risk for falls. While the other patients also have sources
of tethering (e.g., oxygen and IV tubing) and opioid pain medications, the acute
confusion and incontinence along with the IV tethering produce the most
significant risk.
An ambulatory diabetic patient states that she is unable to reach her feet to clip
her toenails. The patient's toenails are long and thick. What is the next step the
nurse should take?
a. Soak the patient's feet, and trim her toenails using clippers.
b. Delegate foot care of this patient to the unlicensed assistive personnel (UAP).
c. Assess the patient's self-care abilities.
d. Ask the primary care provider (PCP) for a referral to a podiatrist.
d. Ask the primary care provider (PCP) for a referral to a podiatrist.
Referral to Podiatrist is appropriate when the diabetic patient is unable to care for
her feet. Soaking is contraindicated for patients with diabetes due to the risk for
skin breakdown. Clippers are not appropriate if nails are thick. Delegating of nail
care to the UAP is inappropriate for patients with peripheral neuropathy. The
nurse already knows the patient's self-care status abilities in regard to her feet.
Which action by a female patient lets the nurse know the patient has understood
perineal care teaching?
a. The patient washes her perineum with a circular motion beginning at the
NURS 100
