NUR 2092/NUR2092 Exam 2 V1 | Health
Assessment Q&A with Rationale |
Rasmussen University
1. When assessing a patient’s lungs, where would the nurse expect to find tactile fremitus
most intense?
A. At the base of the lungs
B. Along the midaxillary line
C. Between the scapulae
D. Over the xiphoid process
Correct Answer: C
Expert Explanation: Tactile fremitus is most intense between the scapulae and near the
sternum where the major bronchi are closest to the chest wall. As the nurse moves away
from these areas towards the lung bases, the intensity of the vibrations normally decreases.
This assessment is performed by asking the patient to repeat phrases like ‘ninety-nine’
while palpating the chest wall.
2. Which heart sound is heard loudest at the apex of the heart?
A. S2
B. S1
C. S3
,D. S4
Correct Answer: B
Expert Explanation: The S1 heart sound, which represents the closure of the
atrioventricular valves, is loudest at the apex. This sound coincides with the carotid artery
pulse and the R wave on an ECG. In contrast, the S2 sound is typically loudest at the base of
the heart.
3. What is the correct sequence for performing an abdominal assessment?
A. Inspection, Palpation, Percussion, Auscultation
B. Inspection, Auscultation, Percussion, Palpation
C. Palpation, Percussion, Auscultation, Inspection
D. Auscultation, Inspection, Palpation, Percussion
Correct Answer: B
Expert Explanation: The correct sequence for an abdominal assessment is inspection
followed by auscultation, percussion, and finally palpation. Auscultation is done second to
avoid stimulating bowel sounds through percussion or palpation, which could lead to false
findings. This unique order ensures the most accurate assessment of bowel activity.
4. A nurse is assessing a patient with a barrel chest. What is the expected ratio of the
anteroposterior (AP) to transverse diameter?
A. 1:2
, B. 2:1
C. 3:4
D. 1:1
Correct Answer: D
Expert Explanation: A barrel chest is characterized by an equal anteroposterior-to-
transverse diameter, resulting in a 1:1 ratio. This condition is often seen in patients with
chronic obstructive pulmonary disease (COPD) due to long-term air trapping. In a healthy
adult, the normal ratio should be approximately 1:2.
5. During percussion of the abdomen, which sound does the nurse expect to hear over most
of the area?
A. Dullness
B. Resonance
C. Tympany
D. Hyperresonance
Correct Answer: C
Expert Explanation: Tympany is the predominant sound heard over the abdomen because
of the presence of air in the stomach and intestines. Dullness is typically only heard over
solid organs like the liver or spleen, or over a full bladder. Identifying these sounds
correctly helps the nurse map out the location and size of internal organs.
Assessment Q&A with Rationale |
Rasmussen University
1. When assessing a patient’s lungs, where would the nurse expect to find tactile fremitus
most intense?
A. At the base of the lungs
B. Along the midaxillary line
C. Between the scapulae
D. Over the xiphoid process
Correct Answer: C
Expert Explanation: Tactile fremitus is most intense between the scapulae and near the
sternum where the major bronchi are closest to the chest wall. As the nurse moves away
from these areas towards the lung bases, the intensity of the vibrations normally decreases.
This assessment is performed by asking the patient to repeat phrases like ‘ninety-nine’
while palpating the chest wall.
2. Which heart sound is heard loudest at the apex of the heart?
A. S2
B. S1
C. S3
,D. S4
Correct Answer: B
Expert Explanation: The S1 heart sound, which represents the closure of the
atrioventricular valves, is loudest at the apex. This sound coincides with the carotid artery
pulse and the R wave on an ECG. In contrast, the S2 sound is typically loudest at the base of
the heart.
3. What is the correct sequence for performing an abdominal assessment?
A. Inspection, Palpation, Percussion, Auscultation
B. Inspection, Auscultation, Percussion, Palpation
C. Palpation, Percussion, Auscultation, Inspection
D. Auscultation, Inspection, Palpation, Percussion
Correct Answer: B
Expert Explanation: The correct sequence for an abdominal assessment is inspection
followed by auscultation, percussion, and finally palpation. Auscultation is done second to
avoid stimulating bowel sounds through percussion or palpation, which could lead to false
findings. This unique order ensures the most accurate assessment of bowel activity.
4. A nurse is assessing a patient with a barrel chest. What is the expected ratio of the
anteroposterior (AP) to transverse diameter?
A. 1:2
, B. 2:1
C. 3:4
D. 1:1
Correct Answer: D
Expert Explanation: A barrel chest is characterized by an equal anteroposterior-to-
transverse diameter, resulting in a 1:1 ratio. This condition is often seen in patients with
chronic obstructive pulmonary disease (COPD) due to long-term air trapping. In a healthy
adult, the normal ratio should be approximately 1:2.
5. During percussion of the abdomen, which sound does the nurse expect to hear over most
of the area?
A. Dullness
B. Resonance
C. Tympany
D. Hyperresonance
Correct Answer: C
Expert Explanation: Tympany is the predominant sound heard over the abdomen because
of the presence of air in the stomach and intestines. Dullness is typically only heard over
solid organs like the liver or spleen, or over a full bladder. Identifying these sounds
correctly helps the nurse map out the location and size of internal organs.
