1. When performing an abdominal assessment, in what order should the nurse
perform the examination techniques?
A. Inspection, Palpation, Percussion, Auscultation
B. Auscultation, Inspection, Palpation, Percussion
C. Inspection, Auscultation, Percussion, Palpation
D. Palpation, Percussion, Auscultation, Inspection
Answer: C
Rationale: In abdominal assessment, auscultation is performed before percussion and
palpation to avoid stimulating bowel sounds which could lead to a false assessment.
2. Which of the following is considered ‘subjective’ data?
A. Blood pressure reading of 120/80 mmHg
B. Pitting edema noted in the lower extremities
C. A visible skin rash on the forearm
D. The patient’s report of a dull, aching pain in the hip
Answer: D
Rationale: Subjective data is what the patient says or feels (symptoms), whereas objective
data is what the nurse observes or measures (signs).
3. The ‘P’ in the PQRST acronym for pain assessment stands for:
A. Pattern
B. Pressure
C. Position
D. Provocation or Palliation
Answer: D
,Rationale: P stands for Provocation/Palliation (what makes it worse or better), Q for
Quality, R for Region/Radiation, S for Severity, and T for Timing.
4. To assess for early jaundice in a dark-skinned patient, the nurse should
inspect the:
A. Abdomen
B. Palms of the hands
C. Nail beds
D. Sclera and hard palate
Answer: D
Rationale: In dark-skinned individuals, jaundice is best observed in the sclera (extending
to the edge of the iris) and the hard and soft palate.
5. While auscultating heart sounds, the nurse knows that the S1 sound is
created by:
A. Closure of the semilunar valves
B. Closure of the atrioventricular valves
C. Opening of the atrioventricular valves
D. The rush of blood into the ventricles
Answer: B
Rationale: S1 (the ‘lub’) occurs with the closure of the AV valves (mitral and tricuspid) and
signals the beginning of systole.
6. The nurse notes a patient has a ‘barrel chest’. This finding is commonly
associated with which condition?
A. Acute pneumonia
B. Chronic obstructive pulmonary disease (COPD)
C. Congestive heart failure
D. Pneumothorax
Answer: B
, Rationale: A barrel chest (increased anteroposterior-to-transverse diameter) is caused by
hyperinflation of the lungs, common in COPD and emphysema.
7. Where is the best location to auscultate the mitral valve?
A. Second right intercostal space
B. Second left intercostal space
C. Fourth left intercostal space
D. Fifth intercostal space at the left midclavicular line
Answer: D
Rationale: The mitral valve (apex of the heart) is best heard at the fifth intercostal space,
left midclavicular line.
8. When assessing skin turgor in an older adult, the nurse should pinch the skin:
A. On the back of the hand
B. On the forearm
C. On the abdomen
D. Over the sternum or under the clavicle
Answer: D
Rationale: In older adults, skin on the hands is often loose and thin; the sternum or
subclavicular area provides a more accurate assessment of turgor/dehydration.
9. The nurse performs the Confrontation Test to assess which of the following?
A. Peripheral vision
B. Extraocular muscle function
C. Near vision acuity
D. Pupillary light reflex
Answer: A
Rationale: The confrontation test is a gross measure of peripheral vision, comparing the
patient’s peripheral vision with the examiner’s.