NURS 104L | Fundamentals of Nursing Skills Lab | Week 5 Assessment
Quiz 2026 |WCU
1. During an abdominal assessment, which is the correct sequence of techniques
to avoid altering bowel sounds?
A. Inspection, Palpation, Percussion, Auscultation
B. Auscultation, Inspection, Palpation, Percussion
C. Inspection, Auscultation, Percussion, Palpation
D. Percussion, Auscultation, Palpation, Inspection
Answer: C
Rationale: In abdominal assessment, auscultation is performed before percussion and
palpation because manual manipulation of the abdomen can stimulate peristalsis and
result in false-positive bowel sounds.
2. When assessing a patient’s blood pressure, the nurse uses a cuff that is too
narrow for the patient’s arm. What is the likely result?
A. A falsely high reading
B. A falsely low reading
C. No change in the reading
D. The diastolic reading will be low, while the systolic will be high
Answer: A
Rationale: Using a blood pressure cuff that is too narrow or too small for the patient’s arm
size results in a falsely high blood pressure reading because more pressure is required to
occlude the artery.
,3. Which heart sound is produced by the closure of the mitral and tricuspid
valves at the beginning of systole?
A. S2
B. S1
C. S3
D. S4
Answer: B
Rationale: S1, the first heart sound, is produced by the closure of the atrioventricular
(mitral and tricuspid) valves and signifies the start of ventricular systole.
4. A nurse is assessing a patient’s respiratory system and hears high-pitched,
musical sounds mainly during expiration. How should the nurse document this?
A. Crackles
B. Pleural friction rub
C. Rhonchi
D. Wheezes
Answer: D
Rationale: Wheezes are high-pitched musical sounds heard primarily during expiration
caused by air flowing through narrowed or obstructed airways.
5. To assess for the presence of a pulse deficit, what action must the nurse take?
A. Measure the apical and radial pulses simultaneously with another nurse
B. Measure the radial pulse for 30 seconds and multiply by 2
C. Measure the carotid and femoral pulses simultaneously
D. Measure the pedal pulse while the patient is standing
Answer: A
Rationale: A pulse deficit is the difference between the apical and radial pulse rates. It
requires two clinicians to measure the pulses at the same time to determine if all heart
contractions are reaching the periphery.
, 6. Which Cranial Nerve is being tested when a nurse asks a patient to stick out
their tongue and move it from side to side?
A. CN IX (Glossopharyngeal)
B. CN X (Vagus)
C. CN XI (Accessory)
D. CN XII (Hypoglossal)
Answer: D
Rationale: Cranial Nerve XII (Hypoglossal) controls the movement of the tongue.
Symmetry and strength are assessed by asking the patient to protrude and move the
tongue.
7. A patient has a 2cm deep indentation that persists for several seconds after
the nurse applies pressure to the pretibial area. How should this be graded?
A. 3+ Edema
B. 2+ Edema
C. 1+ Edema
D. 4+ Edema
Answer: A
Rationale: 3+ pitting edema is characterized by a deep indentation (approximately 6mm)
that remains for a short time (several seconds to a minute).
8. The nurse is assessing a patient’s pupils and notes they constrict when
focusing on a near object after looking at a distant object. This is known as:
A. Accommodation
B. Direct light reflex
C. Consensual light reflex
D. Nystagmus
Answer: A
Quiz 2026 |WCU
1. During an abdominal assessment, which is the correct sequence of techniques
to avoid altering bowel sounds?
A. Inspection, Palpation, Percussion, Auscultation
B. Auscultation, Inspection, Palpation, Percussion
C. Inspection, Auscultation, Percussion, Palpation
D. Percussion, Auscultation, Palpation, Inspection
Answer: C
Rationale: In abdominal assessment, auscultation is performed before percussion and
palpation because manual manipulation of the abdomen can stimulate peristalsis and
result in false-positive bowel sounds.
2. When assessing a patient’s blood pressure, the nurse uses a cuff that is too
narrow for the patient’s arm. What is the likely result?
A. A falsely high reading
B. A falsely low reading
C. No change in the reading
D. The diastolic reading will be low, while the systolic will be high
Answer: A
Rationale: Using a blood pressure cuff that is too narrow or too small for the patient’s arm
size results in a falsely high blood pressure reading because more pressure is required to
occlude the artery.
,3. Which heart sound is produced by the closure of the mitral and tricuspid
valves at the beginning of systole?
A. S2
B. S1
C. S3
D. S4
Answer: B
Rationale: S1, the first heart sound, is produced by the closure of the atrioventricular
(mitral and tricuspid) valves and signifies the start of ventricular systole.
4. A nurse is assessing a patient’s respiratory system and hears high-pitched,
musical sounds mainly during expiration. How should the nurse document this?
A. Crackles
B. Pleural friction rub
C. Rhonchi
D. Wheezes
Answer: D
Rationale: Wheezes are high-pitched musical sounds heard primarily during expiration
caused by air flowing through narrowed or obstructed airways.
5. To assess for the presence of a pulse deficit, what action must the nurse take?
A. Measure the apical and radial pulses simultaneously with another nurse
B. Measure the radial pulse for 30 seconds and multiply by 2
C. Measure the carotid and femoral pulses simultaneously
D. Measure the pedal pulse while the patient is standing
Answer: A
Rationale: A pulse deficit is the difference between the apical and radial pulse rates. It
requires two clinicians to measure the pulses at the same time to determine if all heart
contractions are reaching the periphery.
, 6. Which Cranial Nerve is being tested when a nurse asks a patient to stick out
their tongue and move it from side to side?
A. CN IX (Glossopharyngeal)
B. CN X (Vagus)
C. CN XI (Accessory)
D. CN XII (Hypoglossal)
Answer: D
Rationale: Cranial Nerve XII (Hypoglossal) controls the movement of the tongue.
Symmetry and strength are assessed by asking the patient to protrude and move the
tongue.
7. A patient has a 2cm deep indentation that persists for several seconds after
the nurse applies pressure to the pretibial area. How should this be graded?
A. 3+ Edema
B. 2+ Edema
C. 1+ Edema
D. 4+ Edema
Answer: A
Rationale: 3+ pitting edema is characterized by a deep indentation (approximately 6mm)
that remains for a short time (several seconds to a minute).
8. The nurse is assessing a patient’s pupils and notes they constrict when
focusing on a near object after looking at a distant object. This is known as:
A. Accommodation
B. Direct light reflex
C. Consensual light reflex
D. Nystagmus
Answer: A
