Chapter 03: Techniques of Assessment and Safety

The nurse understands that the preferred method of hand hygiene when hands are not visibly soiled is what?

Alcohol-based rub

The nurse is planning to assess for the presence of lower pitch sounds when examining a patient's heart. Which item of equipment would the nurse use to make this assessment?

Bell of a stethoscope

A nurse is preparing to perform a test for stereognosis in a client. Which piece of equipment should the nurse use?

Coin or key

When assessing pulses, the nurse would use which part of the hand for palpation?

Fingerpads

The nurse is preparing for a physical examination of a client. What should the nurse do first?

Hand hygiene

In the course of performing a client's physical assessment, the nurse has changed from using the diaphragm of the stethoscope to using the bell. The nurse is most likely assessing which of the following?

Heart sounds

The student nurse is caring for a patient with emphysema. What sound would the student nurse expect to hear when percussing the patient's lungs?

Hyperresonant

Which of the following techniques are used in a physical assessment? Select all that apply.

Inspection Palpation Auscultation

A nurse must examine the rectum of a woman who has complained of bleeding from the anus and pain on defecating. Which of the following positions would be most appropriate for the client?

Knee-chest

You should use the bell of the stethoscope when auscultating what type of sounds?

Low-frequency sounds

A nurse recognizes that it is best to begin the objective data collection with which procedure?

Measure the client's vital signs, height, and weight

Which of the following should the nurse do before conducting a physical examination of a client? (Select all that apply.)

Obtain and check needed equipment. Identify ways to ensure patient privacy. Wash hands.

A nurse must assess a client's red reflex. Which piece of equipment will the nurse need for this?

Ophthalmoscope

A nurse, new to the hospital, is attending orientation with the nurse educator. The educator is discussing the use of deep palpation when assessing a patient. The nurse should be aware of what risk when using this assessment technique?

Risk for injury

A nurse has gathered the necessary equipment for the physical assessment of an adult client. It would be most appropriate for a nurse to use a centimeter-scale ruler for which measurement?

Skin lesion size

A nurse is preparing to perform a physical examination of an obese client who is beginning a diet and exercise program. The physician would like to establish a baseline percent body fat measurement for the client so that the client's progress in reducing body fat can be tracked over time. Which piece of equipment should the nurse anticipate needing for this purpose?

Skinfold calipers

A nurse is performing indirect percussion of the lungs on a young woman with pneumonia. Which of the following is the correct hand placement for this technique?

The middle finger of one hand is placed on the body surface and the other middle finger strikes.

Which illustrates the nurse using the technique of inspection?

The nurse detects a fruity odor of the patient's breath.

What is the principle of percussion?

To create vibration in a body wall

While performing the physical examination of a client, a nurse lightly taps certain parts of the body to produce sound waves. What is the purpose of this method of assessment?

To determine whether a structure is filled with air or fluid or is a solid structure

The nurse is gathering the necessary equipment in preparation for examining a client's ears. The nurse will be checking bone and air conduction of sound. What equipment would the nurse obtain?

Tuning fork

How should the nurse place the ear of an adult when using the otoscope?

Up and back

The nurse is caring for the patient who is receiving heparin. The nurse plans to:

Wear clean gloves when administering heparin to the patient

A nurse is examining a client suspected of having a fungal infection of the skin. Which piece of equipment should the nurse use to confirm the presence of fungus?

Wood's light

The nurse is assessing a client's range of motion. Which equipment should the nurse use to validate the degrees of joint mobility?

goniometer

During a comprehensive assessment of the lungs of an adult client with a diagnosis of emphysema, the nurse anticipates that during percussion the client will exhibit

hyperresonance.

The most commonly used method of percussion is

indirect percussion.

A client has an enlarged area on the lower leg. Which technique should the nurse expect to use to assess this body area?

palpation

While performing a physical examination on an adult client, the nurse can detect the density of an underlying structure by using

percussion.

A client is experiencing weakness of the left side of the body. Which piece of equipment should the nurse use to determine if the client's neurologic system is intact?

reflex hammer

The nurse is preparing the examination room before assessing a client. What is the purpose for a clean folded sheet on the examination table?

use as a drape

After the physical examination of a client, a nurse disposes of the used gloves. The nurse has not come in contact with any body fluids or excretion, mucous membranes, nonintact skin, or wound dressings. The nurse's hands do not appear to be visibly soiled. What hand hygiene should the nurse perform?

Application of an alcohol-based hand rub

When performing a physical assessment on an older adult client, what should the nurse consider offering this client?

An extra blanket

Which skin characteristics can a nurse observe by using inspection?

Color

When assessing the temperature of the feet of an older client with diabetes, the nurse would use which part of the hand to obtain the most accurate information?

Dorsal hand surface

A nurse is palpating a child's forehead for signs of fever. Which part of the hand should the nurse use?

Dorsal surface

What assessment technique is performed for every body part and body system?

Inspection

A nurse is beginning the physical examination of an elderly man with chronic obstructive pulmonary disease. In which order should the nurse implement the four physical assessment techniques with this client?

Inspection, palpation, percussion, auscultation

What condition are clients who are frequently hospitalized, as well as nurses, more often diagnosed with than the general population?

Latex allergy

What physical assessment technique should a nurse use to obtain a pulse on a client?

Light palpation

The nurse wears gloves for which of the following purposes? Select all that apply.

Prevent transmission of flora from patient to patient. Limit exposure to body fluids and secretions

The nurse is conducting a physical examination of the abdomen. What is the nurse's best action to ensure she can hear bowel sounds?

Reduce all environmental noise.

For which assessment would the nurse plan to use direct percussion?

Sinuses

A nurse is preparing to perform the physical examination of an adult client who has presented to the clinic for the first time. Which statement would guide the nurse's use of a stethoscope during this phase of assessment?

The diaphragm should be held firmly against the body part.

The nurse is preparing to perform the physical examination of an older adult client who will begin rehabilitation from an ischemic stroke. Which nursing action would be most appropriate?

Try to minimize position changes.

The nurse prepares to use mediate percussion to assess lung tissue. Which action will the nurse take when using this assessment technique?

Use the middle finger to deliver two taps

The nurse is preparing to perform a physical examination on a female client who has been transferred to the medical unit from the emergency department. The nurse should begin the collection of objective data with which examination?

Vital signs

While percussing an adult client during a physical examination, the nurse can expect to hear flatness over the client's

bone.

The nurse selects a tuning fork to use when assessing a client. Which body system is the nurse most likely assessing?

peripheral vascular

After the physical examination of a client, a nurse disposes of the used gloves. The nurse has not come in contact with any body fluids or excretion, mucous membranes, non-intact skin, or wound dressings. The nurse's hands do not appear to be visibly soiled. What hand hygiene should the nurse perform?

Application of an antiseptic handrub

A young adult client has come to the clinic for her scheduled Pap (Papanicolaou) test and pelvic examination. The nurse would implement which action to help reduce the client's anxiety during the physical exam?

Ensuring client's privacy by providing an examination gown

A nurse is examining a child who is suspected of having bronchitis and is preparing to auscultate his chest with a stethoscope. Which of the following actions would demonstrate the correct technique for this procedure?

Ensuring that contact with the skin is maintained

A nurse is preparing to examine a 45-year-old female client with a family history of breast cancer. The nurse explains that she will be performing a routine clinical breast examination of the client today. The client objects to having her breasts examined. How should the nurse respond?

Explain the importance of the examination and the risks of breast cancer

The nurse is performing a physical examination and is using a stethoscope to listen to lung sounds. When using the diaphragm, the nurse would expect to hear lower-pitched sounds.

False

A nurse is preparing to perform intubation on a client. Which pieces of equipment are needed to prevent the transmission of infectious agents during this procedure? Select all that apply.

Gloves Gown Face shield

A nurse will be performing a complete physical examination of a man who has emphysema with a chronic productive cough, including an assessment of his oral cavity. Which pieces of personal protective equipment should the nurse wear?

Gloves, mask, protective eye goggles, gown

In which order should a nurse implement the four physical assessment techniques when initiating a health assessment?

Inspection, palpation, percussion, auscultation

Which of the following statements is true of the role of inspection in the physical examination?

It is often the source of the most physical signs.

Which describes the nurse using the technique of auscultation?

The nurse detects gurgling throughout the abdomen.

Identify the steps in order of priority the nurse takes for performing hand hygiene, from first step to last.

Wet the hands. Apply soap. Scrub the hands together vigorously for 15 seconds. Rinse the hands. Dry hands Turn off faucet with paper towel.