NUR 101/NUR101 Exam 1 V2 | Health
Assessment Q&A with Rationale | Fortis
College
1. A nurse is conducting a health history for a new client. Which of the following information
is considered subjective data?
A. The client’s blood pressure is 140/90 mmHg.
B. The nurse observes the client guarding their abdomen.
C. The client’s skin appears jaundiced and dry.
D. The client reports a frequent headache for the past two days.
Correct Answer: D
Expert Explanation: Subjective data consists of information provided by the patient that
cannot be independently measured or observed by the nurse. This includes symptoms such
as pain, nausea, or feelings described during the interview. In this case, a headache report
is subjective because it relies entirely on the patient’s perception and description.
2. When performing a physical assessment, in what order should the nurse generally perform
the assessment techniques?
A. Palpation, Percussion, Auscultation, Inspection
B. Inspection, Palpation, Percussion, Auscultation
C. Auscultation, Inspection, Palpation, Percussion
,D. Inspection, Auscultation, Palpation, Percussion
Correct Answer: B
Expert Explanation: The standard sequence for a physical assessment is inspection,
palpation, percussion, and then auscultation. Inspection always comes first to gather visual
cues before physically touching the patient. This order is modified only for the abdominal
assessment to avoid altering bowel sounds.
3. A nurse is preparing to assess a client’s abdomen. Which sequence should the nurse use to
avoid altering bowel sounds?
A. Auscultation, Inspection, Palpation, Percussion
B. Inspection, Palpation, Percussion, Auscultation
C. Inspection, Auscultation, Percussion, Palpation
D. Percussion, Auscultation, Inspection, Palpation
Correct Answer: C
Expert Explanation: For an abdominal assessment, the nurse must auscultate before
palpating or percussing. Palpation and percussion can stimulate peristalsis, which may lead
to an inaccurate assessment of bowel sounds. Following this specific sequence ensures the
findings reflect the client’s actual baseline status.
4. The nurse is assessing a client’s radial pulse and notes that it is irregular. What should be
the nurse’s next action?
A. Document the pulse as irregular and continue the assessment.
, B. Assess the radial pulse for a full 60 seconds.
C. Check the carotid pulse to compare the rhythm.
D. Assess the apical pulse for a full minute.
Correct Answer: D
Expert Explanation: When a peripheral pulse is found to be irregular, the apical pulse
must be assessed for one full minute. The apical pulse is the most accurate reflection of the
heart’s rate and rhythm. This action allows the nurse to identify any pulse deficits or
underlying dysrhythmias.
5. A nurse is taking a blood pressure reading and finds that the cuff is too small for the
patient’s arm. What impact will this have on the reading?
A. The blood pressure reading will be falsely low.
B. The size of the cuff does not affect the blood pressure reading.
C. The systolic reading will be accurate, but the diastolic will be high.
D. The blood pressure reading will be falsely high.
Correct Answer: D
Expert Explanation: Using a blood pressure cuff that is too small or narrow will result in a
falsely high reading. The cuff cannot properly compress the artery unless it is sized
correctly for the limb circumference. Nurses must ensure the bladder width is
approximately 40% of the arm circumference for accuracy.
Assessment Q&A with Rationale | Fortis
College
1. A nurse is conducting a health history for a new client. Which of the following information
is considered subjective data?
A. The client’s blood pressure is 140/90 mmHg.
B. The nurse observes the client guarding their abdomen.
C. The client’s skin appears jaundiced and dry.
D. The client reports a frequent headache for the past two days.
Correct Answer: D
Expert Explanation: Subjective data consists of information provided by the patient that
cannot be independently measured or observed by the nurse. This includes symptoms such
as pain, nausea, or feelings described during the interview. In this case, a headache report
is subjective because it relies entirely on the patient’s perception and description.
2. When performing a physical assessment, in what order should the nurse generally perform
the assessment techniques?
A. Palpation, Percussion, Auscultation, Inspection
B. Inspection, Palpation, Percussion, Auscultation
C. Auscultation, Inspection, Palpation, Percussion
,D. Inspection, Auscultation, Palpation, Percussion
Correct Answer: B
Expert Explanation: The standard sequence for a physical assessment is inspection,
palpation, percussion, and then auscultation. Inspection always comes first to gather visual
cues before physically touching the patient. This order is modified only for the abdominal
assessment to avoid altering bowel sounds.
3. A nurse is preparing to assess a client’s abdomen. Which sequence should the nurse use to
avoid altering bowel sounds?
A. Auscultation, Inspection, Palpation, Percussion
B. Inspection, Palpation, Percussion, Auscultation
C. Inspection, Auscultation, Percussion, Palpation
D. Percussion, Auscultation, Inspection, Palpation
Correct Answer: C
Expert Explanation: For an abdominal assessment, the nurse must auscultate before
palpating or percussing. Palpation and percussion can stimulate peristalsis, which may lead
to an inaccurate assessment of bowel sounds. Following this specific sequence ensures the
findings reflect the client’s actual baseline status.
4. The nurse is assessing a client’s radial pulse and notes that it is irregular. What should be
the nurse’s next action?
A. Document the pulse as irregular and continue the assessment.
, B. Assess the radial pulse for a full 60 seconds.
C. Check the carotid pulse to compare the rhythm.
D. Assess the apical pulse for a full minute.
Correct Answer: D
Expert Explanation: When a peripheral pulse is found to be irregular, the apical pulse
must be assessed for one full minute. The apical pulse is the most accurate reflection of the
heart’s rate and rhythm. This action allows the nurse to identify any pulse deficits or
underlying dysrhythmias.
5. A nurse is taking a blood pressure reading and finds that the cuff is too small for the
patient’s arm. What impact will this have on the reading?
A. The blood pressure reading will be falsely low.
B. The size of the cuff does not affect the blood pressure reading.
C. The systolic reading will be accurate, but the diastolic will be high.
D. The blood pressure reading will be falsely high.
Correct Answer: D
Expert Explanation: Using a blood pressure cuff that is too small or narrow will result in a
falsely high reading. The cuff cannot properly compress the artery unless it is sized
correctly for the limb circumference. Nurses must ensure the bladder width is
approximately 40% of the arm circumference for accuracy.
