Chapter 3 Collecting Objective data
A client with scabies visits the health care facility for a follow-up appointment. Which preparation by the nurse is of greatest priority for the physical examination of this client? a) Warm, comfortable room b) Adequate lighting c) Firm examination bed or table d) Quiet area free of disturbance
Adequate lighting Explanation: Adequate lighting is most important for the physical examination of the client with scabies. Sunlight (when available) would be preferable; however, even a portable lamp or a good overhead light is sufficient for illuminating the skin and for viewing shadows and contours. A warm and comfortable room, a quiet area free of disturbance, and a firm examination bed or table are subsequent preparations to the physical setting for the examination.
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? a) Application of an antiseptic handrub b) Nonantimicrobial soap and water with friction c) Hand wash with antiseptic soap d) No washing is needed because hands are not soiled
Application of an antiseptic handrub Explanation: The nurse could apply an antiseptic handrub if the hands do not appear to be soiled. If during the examination the nurse's hands are soiled due to contact with any body fluids or excretion, mucous membranes, non-intact skin, or wound dressings, the nurse would be required to hand wash with nonantimicrobial soap and water, or antiseptic soap.
The nurse enters the room of a client and sees that visitors are present. What is the nurse's best action? a) Politely tell the visitors to leave. b) Ask permission to talk to the client in front of visitors. c) State that the visiting hours are over. d) Make eye contact solely with the client.
Ask permission to talk to the client in front of visitors. Explanation: The nurse should ask permission if visitors are present to find out whether the client wishes them to know information about his condition and treatment. The visitors do not necessarily have to leave the room. If visiting hours are not over, the nurse should not tell visitors they have to leave. Best communication practices include making eye contact with all persons the nurse is speaking to
The client is in a standing position. Which of the following can the nurse most effectively assess with the client in this position? a) Thorax b) Cervical spine c) Balance d) Axillary nodes
Balance Explanation: The standing position is used to assess a client's balance in addition to spine range of motion, and visual acuity. The cervical spine and axillary nodes are assessed with the patient in the seated position. The thorax is assessed in either the sitting or lying position.
A nurse is preparing to perform a physical examination on a young man who appears anxious about the procedure. Which of the following should the nurse do to ease this patient's anxiety? a) Have him undress and put on an examination gown. b) Have him urinate before the examination. c) Perform the genital assessment first to get it over with. d) Before performing each procedure, explain what it involves and its purpose.
Before performing each procedure, explain what it involves and its purpose. Explanation: Throughout the examination, continue to explain what procedure you are performing and why you are performing it. This helps to ease your client's anxiety. If a urine sample is not necessary, ask the client to urinate before the examination to promote an easier and more comfortable examination of the abdomen and genital areas, although it will not likely ease the patient's anxiety. Begin the examination with the less intrusive procedures such as measuring the client's temperature, pulse, blood pressure, height, and weight. These nonthreatening/nonintrusive procedures allow the client to feel more comfortable with you and help to ease client anxiety about the examination.
What can the nurse assess using percussion? a) Borders of the heart b) Movement of the diaphragm during expiration c) Strength of the pulse d) Rectal distension
Borders of the heart Explanation: Percussion allows the examiner to assess such normal anatomic details as the borders of the heart. Options B, C, and D are incorrect because they cannot be assessed by percussion.
A nurse is preparing to evaluate an elderly client's risk for developing pressure sores after a 2-week stay in the hospital. Which of the following pieces of equipment will this nurse need for this purpose? a) Snellen E chart b) Penlight c) Braden scale d) Reflex (percussion) hammer
Braden scale Explanation: The Braden scale for predicting pressure sore risk would be the appropriate tool for evaluating a client's risk for developing pressure sores. The Snellen E chart is used to test distant vision. The penlight is used to view the mouth and throat and to transilluminate the sinuses. The reflex (percussion) hammer is used to test tendon reflexes.
A nurse is preparing to perform a test for stereognosis in a client. Which piece of equipment should the nurse use? a) Tuning fork b) Reflex hammer c) Coin or key d) Tongue depressor
Coin or key Explanation: The nurse needs a coin or a key to test the client for stereognosis, which is the ability to recognize objects by touch. A reflex hammer is used to determine deep tendon reflexes. A tuning fork is used to test for vibratory sensation. A tongue depressor is used to test for the rise of the uvula and gag reflex
The nurse is performing a shift assessment on a client who just received a central line. Which finding should the nurse report as a complication of central line placement? a) Temperature of 97.6 degrees Fahrenheit b) Decreased breath sounds unilaterally c) Respiratory rate of 20 breaths per minute d) Elevated blood pressure while lying in bed
Decreased breath sounds unilaterally Explanation: When a central line is placed, it can lead to a pneumothorax. A sign of a pneumothorax is decreased breath sounds on the affected side. The respiratory rate and temperature readings are expected. Elevated blood pressure is not a complication directly related to central line placement.
A nurse is palpating a child's forehead for signs of fever. Which part of the hand should the nurse use? a) Dorsal surface b) Fingerpads c) Ulnar surface d) Palmar surface
Dorsal surface Explanation: The dorsal (back) surface of the hand is the part most sensitive to temperature and thus is the correct part to use when palpating for temperature. The fingerpads are for fine discriminations, such as for palpating for pulses, texture, size, consistency, shape, and crepitus. The ulnar or palmar surface is used to palpate for vibrations, thrills, and fremitus
The nurse is conducting a physical examination of a patient who is lying down. Which of the following is most appropriate for the nurse to assess while the client is in this position? a) Range of motion of the spine b) Head and neck range of motion c) Dorsiflexion of the foot d) Posterior chest excursion
Dorsiflexion of the foot Explanation: Assessment of dorsiflexion can offer information about problems with the cardiovascular and musculoskeletal systems. Dorsiflexion is best assessed when the client is lying down. Spine range of motion is assessed with the patient in the standing position. Posterior chest excursion and head and neck range of motion are assessed with the patient in the sitting position.
What guidelines should the nurse keep in mind while performing auscultation? a) Use good lighting, preferably sunlight b) Look and observe before touching the client c) Compare appearance of symmetric body parts d) Eliminate distracting noise from the environment
Eliminate distracting noise from the environment Explanation: The auscultation technique requires the use of a stethoscope. The nurse should eliminate any distracting or competing noise from the environment to ensure that the sounds that are heard are those of the client and not the environment. Using good lighting, preferably sunlight, looking and observing before touching the client, and comparing the appearance of symmetric body parts, are some of the guidelines to perform the technique of inspection.
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? a) Using the diaphragm to listen to low-pitched sounds b) Using the bell to detect high-pitched sounds c) Ensuring that contact with the skin is maintained d) Application of firm pressure when using the bell
Ensuring that contact with the skin is maintained Explanation: While using a stethoscope to listen to air movement through the respiratory tract, the nurse should avoid listening through clothing, as it may obscure or alter the sound. However, too much pressure should not be applied when using the bell, as it would cause it to work like a diaphragm. The diaphragm is used to listen to high-pitched sounds, whereas the bell is used to listen to low-pitched sounds.
Which of the following is a general procedural rule when performing a complete physical examination? a) Compare symmetrical body areas. b) Drape primarily for examiner comfort. c) Examine the right then the left side of the body. d) Examine painful areas first.
Examine the right then the left side of the body. Explanation: Beginning examination on the right is the standard practice for the physical examination and has several advantages: it is more reliable to assess jugular veins from the right, the palpating hand rests more comfortably on the apical impulse, and the right kidney is more frequently palpable than the left. Draping provides examinee comfort, and symmetrical areas are not always identical. It is not necessary to begin with areas of pain but rather to proceed systematically
Equipment used in conducting a physical examination includes a 2 × 2 gauze pad. What is this used for? a) Inverting the eyelid b) Invoking the blink reflex c) Examining the tongue d) Testing facial sensation
Examining the tongue Explanation: 2 × 2 gauze pads are used during tongue examination.
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. a) Face shield b) Gown c) Gloves d) Nasopharyngeal airway e) Stethoscope
Face shield • Gloves • Gown Correct Explanation: The specific personal protective equipment needed to prevent the transmission of infectious agents varies depending on the procedure to be performed. For example, performing venipuncture requires only gloves, but intubation requires gloves, gown, and face shield, mask, or goggles. A nasopharyngeal airway may be needed for intubation, but its purpose is not to prevent transmission of infectious agents. A stethoscope would not be needed for this procedure.
A nurse needs to measure the degree of flexion and extension that a student athlete has available at his knee joint 6 weeks after orthopedic surgery. Which of the following pieces of equipment would be best for the nurse to use? a) Flexible metric measuring tape b) Skinfold calipers c) Goniometer d) Reflex hammer
Goniometer Explanation: A goniometer is a device used for measuring the degree of flexion and extension available at a joint. A reflex (percussion) hammer is used to test deep tendon reflexes, such as the patellar reflex of the knee. Skinfold calipers are used to measure skinfold thickness of subcutaneous tissue. A flexible metric measuring tape may be used for many purposes, including measuring the size of extremities.
What is the single most important method of preventing infection transmission by the nurse when coming into contact with a client? a) Using eye protection b) Gowning c) Handwashing d) Wearing latex gloves
Handwashing Explanation: Contact transmission from the hands of all health care providers to clients is the most common mode of transmission, because microorganisms from one client are then spread to others. Wearing latex gloves is one step in preventing infection transmission but not the most important. Using eye protection and gowning are important in certain infection transmission situations, but again, not the most important.
A nurse performs an admission assessment on a client admitted with chest pain. The nurse knows that using the bell of the stethoscope is appropriate to auscultate for which type of sounds? a) Bowel b) Normal heart c) Heart murmur d) Breath
Heart murmur Explanation: The bell of the stethoscope is used to listen for low pitched sounds such as abnormal heart sounds or bruits. The diaphragm is used to listen for high pitched sounds such as normal heart, lung, & bowel sounds
In which order should a nurse implement the four physical assessment techniques when initiating a health assessment? a) Inspection, palpation, percussion, auscultation b) Inspection, auscultation, percussion, palpation c) Auscultation, percussion, palpation, inspection d) Percussion, palpation, inspection, auscultation
Inspection, palpation, percussion, auscultation Explanation: Inspection is the first physical assessment technique that a nurse should implement. This prevents altering the appearance of structures that may distract the nurse from completing a focused observation.
Which of the following statements is true of the role of inspection in the physical examination? a) It should be performed after auscultation but before palpation and percussion. b) To maximize findings, local inspection should be conducted prior to general inspection. c) It is often the source of the most physical signs. d) The acuity of the client will determine whether general or local inspection should be implemented in the examination.
It is often the source of the most physical signs. Explanation: Inspection often yields the most signs during an examination. It should begin the examination, and general inspection precedes local inspection. The two are not mutually exclusive and should both be implemented in each examination.
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? a) Prone b) Dorsal recumbent c) Supine d) Knee-chest
Knee-chest Explanation: The knee-chest position is useful for examining the rectum. In this position, the client kneels on the examination table with the weight of the body supported by the chest and knees. In the prone position, the client lies down on the abdomen with the head to the side. The prone position is used primarily to assess the hip joint. In the supine position, the client lies down with the legs together on the examination table. This position allows the abdominal muscles to relax and provides easy access to peripheral pulse sites. Areas assessed with the client in this position may include the head, neck, chest, breasts, axillae, abdomen, heart, lungs, and all extremities. In the dorsal recumbent position, the client lies down on the examination table or bed with the knees bent, the legs separated, and the feet flat on the table or bed. Areas that may be assessed with the client in this position include the head, neck, chest, axillae, lungs, heart, extremities, breasts, and peripheral pulses.
The nurse is assessing a client with unexplained lesions noted on the client's back. The nurse is going to palpate the area of the lesions. What type of palpation should the nurse use? a) Moderate b) Deep c) Intermediate d) Light
Light Explanation: Light palpation is appropriate for the assessment of surface characteristics, such as texture, surface lesions or lumps, or inflamed areas of skin. Moderate palpation should be used to assess the size, shape, and consistency of abdominal organs. Pressure is firm enough to depress approximately 1 to 2 cm in depth. During deep palpation, the nurse uses a pressure to palpate 2 to 4 cm in depth. Intermediate palpation is a distracter for this question.
What physical assessment technique should a nurse use to obtain a pulse on a client? a) Moderate palpation b) Deep palpation c) Light palpation d) Bimanual palpation
Light palpation Explanation: The nurse should use the light palpation technique to check the pulse of the client. Moderate and bimanual palpation is used to note the size, consistency, and mobility of the structures that are palpated. Deep palpation enables the nurse to feel very deep organs or structures that are covered by thick muscles
A nurse is preparing to perform a genital examination of a female client. Which of the following positions should the nurse place the client in? a) Supine b) Standing c) Lithotomy d) Prone
Lithotomy The lithotomy position is used to examine the female genitalia, reproductive tracts, and the rectum. It involves the client lying on her back with the hips at the edge of the examination table and the feet supported by stirrups. In the supine position, the client lies down with the legs together on the examination table. This position allows the abdominal muscles to relax and provides easy access to peripheral pulse sites. Areas assessed with the client in this position may include the head, neck, chest, breasts, axillae, abdomen, heart, lungs, and all extremities. In the standing position, the client stands still in a normal, comfortable, resting posture. This position allows the examiner to assess posture, balance, and gait. This position is also used for examining the male genitalia. In the prone position, the client lies down on the abdomen with the head to the side. The prone position is used primarily to assess the hip joint.
You should use the bell of the stethoscope when auscultating what type of sounds? a) Sounds that are partially audible without a stethoscope b) High-frequency sounds c) Abnormal sounds d) Low-frequency sounds
Low-frequency sounds Explanation: The bell is used with light skin contact to hear low-frequency sounds
As the density of tissue decreases, the percussion note becomes: a) Less musical b) Lower pitched c) Softer d) Shorter
Lower pitched Explanation: Low density tissue tends to produce sound that is lower pitched, musical, loud, and longer in duration than in denser tissue.
During the physical examination of your patient you auscultate the sound of the patient's breathing. What area of the patient are you assessing? a) Neck b) Abdomen c) Back d) Lungs
Lungs Explanation: To assess the patient's breathing sounds, the nurse auscultates the lungs using the stethoscope.
A nurse recognizes that it is best to begin the objective data collection with which procedure? a) Measure the client's vital signs, height, and weight b) Auscultation of all necessary body systems to prevent disturbing any organs c) Begin at the head and move in a systematic approach d) Allow the client to undress and put on a gown
Measure the client's vital signs, height, and weight Explanation: It is important to begin the assessment with less intrusive procedures such as vital signs and height & weight. These nonthreatening/nonintrusive procedures allow the client to feel more comfortable with the nurse and ease anxiety. Once a trusting relationship is established, the nurse can proceed in a systematic approach to ensure that all body systems are fully examined. Auscultation of all body systems is not an acceptable approach to a comprehensive assessment. The initial assessment data can be collected while the client is still dressed
A nurse performs indirect palpation of an underlying structure correctly when the hands are placed in which position? a) 1-2 fingers are placed over the body structure and the fingertips are used to tap the skin surface b) Ulnar surface of one hand is placed against the body surface and vibrations are felt c) Middle finger of one hand is placed on the body surface and the other middle finger strikes d) One hand is placed flat against the body and the fist of the other hand strikes the back of the flat hand
Middle finger of one hand is placed on the body surface and the other middle finger strikes Explanation: Indirect percussion is the most commonly used of the percussion techniques. This method entails the middle finger of the nondominant hand to be placed on the body surface to be assessed. Keeping all other fingers off the body surface, strike this finger with the other middle finger. Direct percussion is when 1-2 fingers are placed over the body structure and the fingertips are used to tap the skin surface. Placing the ulnar surface of one hand against the body surface and feeling the vibrations is a form of palpation. Blunt palpation involves placing one hand flat against the body and the fist of the other hand strikes the back of the flat hand.
A nurse must assess a client's red reflex. Which piece of equipment will the nurse need for this? a) Otoscope b) Ophthalmoscope c) Penlight d) Tuning fork
Ophthalmoscope Explanation: An ophthalmoscope is used to view the red reflex and to examine the retina of the eye. A tuning fork is used to test for bone and air conduction of sound. An otoscope is used to view the ear canal and tympanic membrane. A penlight is used to view the mouth and throat and to transilluminate the sinuses.
During a physical examination of a client, the nurse assesses the size of the liver. Which of the following techniques should the nurse use for this assessment? a) Palpation b) Inspection c) Percussion d) Auscultation
Palpation Explanation: Palpation is the use of tactile pressure from the fingers to assess contours and sizes of organs. Inspection is close observation of the details of a client's appearance, behavior, and movement. Percussion is the use of a finger of one hand to strike a finger of another hand for the purpose of eliciting a tone or sound wave. Auscultation is the use of a stethoscope to heart sounds within the body organs.
For which assessment would the nurse plan to use light palpation? a) Size of liver b) Pulsation of abdominal aorta c) Shape of abdominal mass d) Papular rash
Papular rash Explanation: Light palpation is used to assess surface characteristics, such as a papular rash. Deep palpation is used to assess the size, shape, and consistency of abdominal organs.
While performing a physical examination on an adult client, the nurse can detect the density of an underlying structure by using a) palpation. b) Doppler magnification. c) percussion. d) inspection.
Percussion involves tapping body parts to produce sound waves. These sound waves or vibrations enable the examiner to assess underlying structures.
A nurse experiences difficulty auscultating the heart sounds of a client. What should the nurse do to enhance the sounds of the heart tones? Select all that apply. a) Tell the client to hold their breathe b) Readjust the ear pieces to ensure a snug fit c) Eliminate distracting noises from the environment d) Place the diaphragm against the client's clothing e) Angle the binurals towards the nose
Readjust the ear pieces to ensure a snug fit • Eliminate distracting noises from the environment • Angle the binurals towards the nose Explanation: To enhance the sounds from the stethoscope, the nurse should eliminate distracting or competing sound from the environment. The ear piece should fit comfortably but snugly in to the ear canals with the binurals towards the nose to ensure the sounds are transmitted to the ear drums. The stethoscope should be places against the client's skin to prevent rubbing of the clothing.
The nurse is conducting a physical examination of the abdomen. What is the nurse's best action to ensure she can hear bowel sounds? a) Reduce all environmental noise. b) Percuss the region before auscultating. c) Palpate the region before auscultating. d) Assist the client to a sitting position.
Reduce all environmental noise. Explanation: Auscultating bowel sounds can be difficult because of environmental noise. The nurse should reduce all environmental noise and auscultate the bowel sounds again. The steps used to assess the abdomen are inspection, auscultation, percussion, and palpation. The techniques of percussion and palpation will cause the patient to experience bowel sounds and, therefore, should be performed after bowel sounds are auscultated. Assessment of the abdomen is best performed with the patient in the lying position.
A nurse is performing percussion on a client's back to assess the lungs, and hears a loud, low-pitched, hollow sound, indicating normal lungs. Which of the following describes this finding? a) Dullness b) Tympany c) Hyper-resonance d) Resonance
Resonance is a loud, low-pitched, hollow sound normally percussed over an area that is part air and part solid, which is expected over normal lung fields. Hyper-resonance is a very loud, low-pitched sound that is normally heard in lungs with a lot of air such as in emphysema. Tympany is a very loud, high-pitched, drumlike sound that is heard over an air-filled structure, such as the stomach. Dullness is a medium-pitched, thudlike sound that is percussed over solid tissue such as the liver.
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? a) Risk for chronic pain b) Risk for infection c) Risk for injury d) Risk for impaired skin integrity
Risk for injury Explanation: With deep palpation, you might say, "I'm going to touch you and push down more deeply than before. Let me know if you feel pain or want me to stop." As palpation proceeds, continue conversation, asking the patient about pain, presenting symptoms, or contributing factors while observing for nonverbal signs of tenderness or discomfort.
For which of the following assessments would the nurse plan to use deep palpation? (Select all that apply.) a) Texture of a mole b) Pulsation of abdominal aorta c) Shape of abdominal mass d) Size of liver e) Macular rash
Shape of abdominal mass • Size of liver • Pulsation of abdominal aorta Explanation: Deep palpation is used to assess the size, shape, and consistency of abdominal organs. Light palpation is used to assess surface characteristics, such as a macular rash and texture of a mole.
For which assessment would the nurse plan to use deep palpation? a) Skin temperature b) Texture of a mole c) Size of liver d) Macular rash
Size of liver Explanation: Deep palpation is used to assess the size, shape, and consistency of abdominal organs. Light palpation is used to assess surface characteristics, such as skin temperature, texture of a mole, and a macular rash
What is used to gauge central and peripheral nervous system disorders? a) Gait b) Strength of a reflex c) Heat and cold d) Tuning fork
Strength of a reflex Explanation: The strength of a reflex is used to gauge central and peripheral nervous system disorders.
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? a) One to two fingers are placed over the body structure and the fingertips are used to tap the skin surface. b) One hand is placed flat against the body and the fist of the other hand strikes the back of the flat hand. c) The middle finger of one hand is placed on the body surface and the other middle finger strikes. d) The ulnar surface of one hand is placed against the body surface and vibrations are felt.
The middle finger of one hand is placed on the body surface and the other middle finger strikes. Explanation: Indirect percussion is the most commonly used of the percussion techniques. This method entails the middle finger of the nondominant hand being placed on the body surface to be assessed. Keeping all other fingers off the body surface, strike this finger with the other middle finger. Direct percussion is when 1-2 fingers are placed over the body structure and the fingertips are used to tap the skin surface. Placing the ulnar surface of one hand against the body surface and feeling the vibrations is a form of palpation. Blunt palpation involves placing one hand flat against the body and striking the back of the flat hand with the fist of the other hand.
Which describes the nurse using the technique of auscultation? a) The nurse detects foul odor of the urine. b) The nurse detects gurgling throughout the abdomen. c) The nurse notes dullness over the liver. d) The nurse notes a small nodule in the breast.
The nurse detects gurgling throughout the abdomen. Correct Explanation: Auscultation is used by the nurse to assess bowel sounds, such as gurgling throughout the abdomen. Inspection involves conscious observation of the patient's physical characteristics and behaviors and smelling for odors, such as foul smelling urine. The nurse uses palpation to detect nodules in the breast by the use of touch. The nurse uses the technique of percussion to produce sounds over various parts of the body, such as dullness over the liver.
Which describes the nurse using the technique of palpation? a) The nurse notes tympany over the individual's lower abdomen. b) The nurse notes gurgling sounds over the individual's abdomen. c) The nurse notes asymmetry of the individual's abdomen. d) The nurse notes increased warmth surrounding an abdominal incision.
The nurse notes increased warmth surrounding an abdominal incision. Explanation: The nurse uses palpation to assess the individual through touch, such as to detect increased warmth surrounding an incision. Inspection involves smelling for odors and conscious observation of the patient's physical characteristics and behaviors, such as noting the symmetry of the abdomen. Auscultation is used by the nurse to assess bowel sounds. The nurse detects tympanic sounds of the bowel by percussing the abdomen.
Which describes the nurse using the technique of percussion? a) The nurse detects rustling over the individual's thorax. b) The nurse notes resonance over the individual's thorax. c) The nurse notes symmetry of the individual's thorax. d) The nurse detects crepitus over the individual's thorax.
The nurse notes resonance over the individual's thorax. Correct Explanation: The nurse uses the technique of percussion to produce sounds over various parts of the body. The nurse detects resonance over the lungs by percussing the thorax. Inspection involves smelling for odors and conscious observation of the patient's physical characteristics and behaviors, such as noting symmetry of the thorax. The nurse uses palpation to detect crepitus over the thorax by the use of touch. Auscultation is used by the nurse to assess lung sounds, such as rustling. (
For which patient should the nurse wear gloves to provide care? Select all that apply. a) The patient who self-administer heparin b) The patient continent of urine c) The patient requiring oropharyngeal suctioning d) The patient with Clostridium difficile e) The patient with vancomycin-resistant enterococci
The patient requiring oropharyngeal suctioning • The patient with Clostridium difficile • The patient with vancomycin-resistant enterococci Correct Explanation: The nurse wears gloves when contact with any body secretions and fluids is possible. The nurse wears gloves to provide care for patients with infections of Clostridium difficile or vancomycin-resistant enterococci and patients requiring oropharyngeal suctioning. Gloves are not necessary when caring for a continent patient or a patient who self-administer heparin.
A nurse is palpating a client's chest for vibration as he inhales and exhales. Which part of the hand should the nurse use in this case? a) Palmar surface b) Fingerpads c) Dorsal surface d) Fingertips
The ulnar—or palmar—surface is the part of the hand used to palpate vibrations. The fingertips are not used to palpate. The dorsal surface is sensitive to temperature and the fingerpads are used to detect fine discriminations, such as pulses, texture, size, consistency, shape, and crepitus.
Sometimes it is necessary to use a tuning fork when performing a physical assessment. What would be one instance where a tuning fork would be used? a) To determine vibration sense in the neuromuscular system b) To determine reflex sensation in the legs c) To determine genetic hearing loss in infants d) To determine sensation in the scalp
To determine vibration sense in the neuromuscular system Explanation: The tuning fork is used with two body systems: to determine vibration sense in the neuromuscular system and to determine conductive versus sensorineural hearing loss in the ears. The other options are distracters to the question.
It is recommended that a left-handed examiner adopt a right-sided position. a) True b) False
True
The nurse is admitting a client to the surgical unit. The nurse should begin the general survey at which point in the admission process? a) As soon as any visitors have left the room b) After the physical examination is completed c) Upon meeting the client and family members d) When the demographic data has been documented
Upon meeting the client and family members Explanation: The general survey begins immediately when meeting the client and continues throughout the assessment.
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? a) Wood's light b) Examination light c) Penlight d) Magnifying glass
Wood's light Correct Explanation: Wood's light is a special piece of examination equipment that is used to test for fungus. A penlight is used for more general assessments, such as of the mouth and throat and to transilluminate the sinuses. A magnifying glass is used to enlarge the visibility of a lesion. An examination light is used to better illuminate the client's body as a whole to facilitate physical examination.
While percussing an adult client during a physical examination, the nurse can expect to hear flatness over the client's a) liver. b) lungs. c) bone. d) abdomen.
bone. Explanation: Flatness is a sound heard over very dense tissue like bone.
The nurse is conducting a physical examination of a client who is in the lying position. Place in order the areas the nurse will assess when completing this examination. a. Shins and ankles b. Groin, hips, and knees c. Breasts d. Chest and thorax e. Cardiovascular a) c, d, e, b, a b) a, c, b, d, e c) d, e, b, a, c d) c, e, b, d, a e) d, b, a, e, c
c, d, e, b, a Explanation: When conducting a head-to-toe assessment for a client in the lying position, the nurse should begin with the structures closest to the head and progress downward. The nurse will assess the breasts, the chest and thorax, the cardiovascular system, the groin, hips, and knees, and then the shins and ankles
During palpation of a client's organs, the nurse palpates the spleen by applying pressure between 2.5 and 5 cm. The nurse is performing a) moderate palpation. b) light palpation. c) very deep palpation. d) deep palpation.
deep palpation. Explanation: Deep palpation depresses the surface between 2.5 and 5 cm (1 and 2 inches). This allows you to feel very deep organs or structures that are covered by thick muscle.
Light palpation is most appropriate to assess the a) appendix b) bladder c) liver d) inflamed areas of skin
inflamed areas of skin Explanation: Light palpation is appropriate for the assessment of surface characteristics, such as texture, surface lesions or lumps, or inflamed areas of skin
To adhere to standard precautions, the nurse should remember to (Select all that apply.) a) put on a cover gown when entering a patient's room b) wear gloves with each patient contact c) wash hands before and after patient contact d) change white coat frequently
wash hands before and after patient contact • change white coat frequently
Which of the following techniques are used in a physical assessment? Select all that apply. a) Inspection b) Questioning c) Subjectivity d) Palpation e) Auscultation
• Auscultation • Palpation • Inspection Explanation: The four techniques of inspection, palpation, percussion, and auscultation form the basis for physical assessment. Subjectivity and questioning are distracters for this question.
Which of the following should the nurse do before conducting a physical examination of a client? (Select all that apply.) a) Dim the lighting to promote comfort b) Obtain and check needed equipment. c) Identify ways to ensure patient privacy. d) Turn on relaxing music of the client's choice e) Wash hands.
• Identify ways to ensure patient privacy. • Obtain and check needed equipment. • Wash hands. Correct Explanation: Prior to conducting a physical examination of a patient, the nurse should obtain and check needed equipment, identify how to maintain patient privacy during the examination, and wash hands before beginning the examination. Having any additional noise in the background will make it difficult to obtain an accurate assessment. All environmental noise should be removed as much as possible. Good lighting is needed to ensure an accurate assessment. Dim lights can prevent getting a good visual of the area being assessed.
