NUR 101/NUR101 Exam 2 V3 | Health
Assessment Q&A with Rationale | Fortis
College
1. Which of the following occurrences describes the production of the S2 heart sound?
A. Closure of the atrioventricular valves.
B. Opening of the atrioventricular valves.
C. Opening of the semilunar valves.
D. Closure of the semilunar valves.
Correct Answer: D
Expert Explanation: The S2 heart sound, commonly referred to as ‘dub,’ is produced by
the closure of the aortic and pulmonic semilunar valves. It marks the end of systole and the
beginning of diastole. This sound is best auscultated at the base of the heart using the
diaphragm of the stethoscope.
2. A patient presents with a high-pitched, musical squeaking sound heard primarily during
expiration. How should the nurse document this finding?
A. Crackles
B. Wheezes
C. Rhonchi
D. Pleural friction rub
,Correct Answer: B
Expert Explanation: Wheezes are continuous, high-pitched musical sounds resulting from
air flowing through narrowed or obstructed airways. They are frequently associated with
conditions such as asthma, bronchitis, or emphysema. The nurse must specifically note
whether the sounds occur during inspiration, expiration, or both for accurate reporting.
3. When assessing tactile fremitus, the nurse asks the patient to repeat the phrase ‘ninety-
nine.’ What is the nurse palpating for?
A. Skin temperature
B. Masses
C. Tenderness
D. Vibrations
Correct Answer: D
Expert Explanation: Tactile fremitus involves the palpation of vibrations transmitted
through the bronchopulmonary system to the chest wall. The nurse uses the palmar base or
the ulnar edge of the hand to feel for these vibrations. Increased fremitus typically suggests
consolidation of lung tissue, such as in pneumonia.
4. To auscultate the aortic valve area, where should the nurse place the stethoscope?
A. Second right intercostal space
B. Second left intercostal space
, C. Fourth left intercostal space
D. Fifth intercostal space at the midclavicular line
Correct Answer: A
Expert Explanation: The aortic area is located at the second right intercostal space at the
right sternal border. This specific anatomical landmark allows the nurse to best hear the
sounds produced by the closure of the aortic valve. It is the first step in the traditional ‘Z-
pattern’ of cardiac auscultation.
5. In what order should the nurse perform the components of an abdominal assessment?
A. Inspection, Palpation, Percussion, Auscultation
B. Palpation, Inspection, Auscultation, Percussion
C. Inspection, Auscultation, Percussion, Palpation
D. Auscultation, Inspection, Percussion, Palpation
Correct Answer: C
Expert Explanation: The order of abdominal assessment is modified to prevent the
stimulation of bowel sounds through palpation or percussion. By auscultating immediately
after inspection, the nurse ensures a true representation of the patient’s bowel activity.
This protocol is essential for accurate diagnosis of conditions such as paralytic ileus or
bowel obstruction.
Assessment Q&A with Rationale | Fortis
College
1. Which of the following occurrences describes the production of the S2 heart sound?
A. Closure of the atrioventricular valves.
B. Opening of the atrioventricular valves.
C. Opening of the semilunar valves.
D. Closure of the semilunar valves.
Correct Answer: D
Expert Explanation: The S2 heart sound, commonly referred to as ‘dub,’ is produced by
the closure of the aortic and pulmonic semilunar valves. It marks the end of systole and the
beginning of diastole. This sound is best auscultated at the base of the heart using the
diaphragm of the stethoscope.
2. A patient presents with a high-pitched, musical squeaking sound heard primarily during
expiration. How should the nurse document this finding?
A. Crackles
B. Wheezes
C. Rhonchi
D. Pleural friction rub
,Correct Answer: B
Expert Explanation: Wheezes are continuous, high-pitched musical sounds resulting from
air flowing through narrowed or obstructed airways. They are frequently associated with
conditions such as asthma, bronchitis, or emphysema. The nurse must specifically note
whether the sounds occur during inspiration, expiration, or both for accurate reporting.
3. When assessing tactile fremitus, the nurse asks the patient to repeat the phrase ‘ninety-
nine.’ What is the nurse palpating for?
A. Skin temperature
B. Masses
C. Tenderness
D. Vibrations
Correct Answer: D
Expert Explanation: Tactile fremitus involves the palpation of vibrations transmitted
through the bronchopulmonary system to the chest wall. The nurse uses the palmar base or
the ulnar edge of the hand to feel for these vibrations. Increased fremitus typically suggests
consolidation of lung tissue, such as in pneumonia.
4. To auscultate the aortic valve area, where should the nurse place the stethoscope?
A. Second right intercostal space
B. Second left intercostal space
, C. Fourth left intercostal space
D. Fifth intercostal space at the midclavicular line
Correct Answer: A
Expert Explanation: The aortic area is located at the second right intercostal space at the
right sternal border. This specific anatomical landmark allows the nurse to best hear the
sounds produced by the closure of the aortic valve. It is the first step in the traditional ‘Z-
pattern’ of cardiac auscultation.
5. In what order should the nurse perform the components of an abdominal assessment?
A. Inspection, Palpation, Percussion, Auscultation
B. Palpation, Inspection, Auscultation, Percussion
C. Inspection, Auscultation, Percussion, Palpation
D. Auscultation, Inspection, Percussion, Palpation
Correct Answer: C
Expert Explanation: The order of abdominal assessment is modified to prevent the
stimulation of bowel sounds through palpation or percussion. By auscultating immediately
after inspection, the nurse ensures a true representation of the patient’s bowel activity.
This protocol is essential for accurate diagnosis of conditions such as paralytic ileus or
bowel obstruction.
