Chapter 3: Collecting Objective Data: The Physical Examination

When is it necessary for a nurse to change gloves?

-Between tasks and procedures on the same client -When going from a contaminated area to a cleaner area -After contact with material that contains a high concentration of microorganisms

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?

-Gloves -Gown -Face shield

What included in personal protective equipment?

-Gloves -Gown -Mouth, nose, eye protection

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

-Inspection -Palpation -Auscultation

For which client should the nurse wear gloves to provide care?

-The client with Clostridium difficile -The client with vancomycin-resistant enterococci -The client requiring oropharyngeal suctioning

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?

Adequate lighting

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

The client is in a standing position. Which of the following can the nurse most effectively assess with the client in this position?

Balance

The nurse is conducting a physical examination of a client. After completing the examination, the nurse realizes that part of the examination was omitted by mistake. How should the nurse proceed?

Complete the forgotten portion of the exam out of sequence.

A student nurse is palpating the neck of a client who reports a lump behind the ear. While palpating, the student nurse notes that the lump is immobile. Which action by the student nurse is best in response to this finding?

Consult with a clinical instructor.

A nurse on an oncology unit enters a client's room to auscultate bowel sounds. What should the nurse do before auscultating?

Disinfect the stethoscope before touching the client

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

Dorsal surface

The nurse would use what part of the hand when assessing temperature during palpation?

Dorsal surface

The nurse is conducting a physical examination of a client who is lying down. Which is the most appropriate for the nurse to assess while the client is in this position?

Dorsiflexion of the foot

A nurse is preparing to perform auscultation on a client. Which guideline is most important for the nurse to keep in mind while performing this technique?

Eliminate distracting noises from the environment.

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

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

Finger pads

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

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

Hand hygiene

A nurse needs to obtain a pulse on a client. Which physical assessment technique should the nurse use?

Light palpation

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

Light palpation

Which is the priority for the nurse conducting a physical examination of a client with generalized muscle weakness?

Limit position changes as much as possible

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?

Lithotomy

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

Low-frequency sounds

During the physical examination of your client you auscultate the sound of the client's breathing. What area of the client are you assessing?

Lungs

A nurse is preparing to physically examine a client. The nurse recognizes that it is best to begin the objective data collection with which procedure?

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

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?

Palpation

What would be the expected tone elicited by percussion of a normal lung?

Resonance

The nursing instructor is discussing standard precautions with a group of students. What else should the instructor talk about to prevent the transmission of pathogens?

Respiratory/cough hygiene

What auscultation sound would the nurse expect when listening to heart sounds?

Rhythmic lub-dub

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 client with an inability to read billboards while driving arrives at the health care facility for an eye examination. Which piece of equipment should the nurse use to check the client's distant vision?

Snellen chart

Which describes the nurse using the technique of auscultation?

The nurse detects gurgling throughout the abdomen.

Which describes the nurse using the technique of percussion?

The nurse notes resonance over the individual's thorax.

Palpation is a necessary skill in nursing. Many of the body's structures, even though they are not visible, can be assessed through palpation. Which structures would be included in assessment by palpation?

Thyroid gland

A nurse in the community is completing manual blood pressure assessments at a recreation center. Which action should the nurse take to ensure the assessment is accurate?

Turn down the volume if the television or radio is on.

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

Up and back

When the nurse places one hand flat on the body surface and uses the fist of the other hand to strike the back of the hand flat on the body surface, the nurse is using

blunt percussion.

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

bone.

The nurse observes a student nurse performing a focused assessment on a client presenting with signs and symptoms of appendicitis. The nurse should intervene when the student nurse is observed performing which of the following actions on the client's abdomen?

deep palpation

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

deep palpation.

The most commonly used method of percussion is

indirect percussion.

The nurse is beginning a physical examination of a client. Which technique should the nurse use for every body part and system?

inspection

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