chapter 3
A nurse is preparing to perform a test for stereognosis in a client. Which piece of equipment should the nurse use? Reflex hammer Tuning fork Coin or key 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.
What assessment technique is performed for every body part and body system?
Inspection Explanation: Inspection is the one technique that is performed for every body part and body system. Other techniques are not used for every body part and system.
While performing a physical examination on an adult client, the nurse can detect the density of an underlying structure by using palpation. inspection. percussion. Doppler magnification.
percussion. Explanation: Percussion involves tapping body parts to produce sound waves. These sound waves or vibrations enable the examiner to assess underlying structures.
Universal precautions are primarily designed to protect the health care worker from what? Respiratory diseases Blood-borne pathogens Musculoskeletal injuries STDs
Blood-borne pathogens Explanation: Universal precautions are a set of guidelines designed to prevent transmission of HIV, hepatitis B virus, and other blood-borne pathogens when providing first aid or health care.
Which of the following would be most important for the nurse to do immediately before beginning the physical exam? Collect necessary equipment essential to the exam. Construct the client's family genogram. Establish the client's reliability as historian. Practice interviewing skills.
Collect necessary equipment essential to the exam. Explanation: Collecting all equipment for the exam promotes organization, displays competence, and avoids having to leave the client to obtain missing items. Interviewing skills are important for obtaining the health history. Constructing a genogram is part of the data collected for family health history. Establishing the client's reliability as a historian should be done before obtaining the health history.
A nurse is palpating a child's forehead for signs of fever. Which part of the hand should the nurse use? Finger pads Dorsal surface Palmar surface Ulnar 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 finger pads 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.
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. Use good lighting, preferably sunlight. Look and observe before touching the client. Compare appearance of symmetric body parts.
Eliminate distracting noises from the environment. Explanation: The auscultation technique requires the use of a stethoscope. The nurse should eliminate any distracting or competing noises from the environment to ensure that the sounds 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 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? Ask the physician to perform the examination Insist that the client undress and allow her breasts to be examined, for her own good Explain the importance of the examination and the risks of breast cancer Comply with the client's request and proceed with the rest of the examination
Explain the importance of the examination and the risks of breast cancer Explanation: If a client requests that a certain part of the examination, such as the breast examination, not be performed, the nurse should explain the importance of the examination and the risk of missing important information if any part is omitted. Simply complying with the client's request, insisting on the examination, and asking the physician to perform it would not be appropriate actions.
The nurse is using a Wood's light for a client who has complaints of itching, burning, and peeling of the skin between his toes. The nurse is assessing for what etiology of the client's symptoms? Fungal infection Bacterial infection Allergic reaction Parasitic infection
Fungal infection Explanation: A Wood's light is used to assess for fungal infections.
A nurse needs to obtain a pulse on a client. Which physical assessment technique should the nurse use? Bimanual palpation Moderate palpation Deep palpation Light palpation
Light palpation Explanation: The nurse should use the light palpation technique to check the pulse of the client. Moderate and bimanual palpations are 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.
You should use the bell of the stethoscope when auscultating what type of sounds? Low-frequency sounds Abnormal sounds Sounds that are partially audible without a stethoscope High-frequency sounds
Low-frequency sounds Explanation: The bell is used with light skin contact to hear low-frequency sounds.
The nurse is planning to assess a client from head to toe. Which equipment should the nurse prepare to use first?
Snellen chart Explanation: If assessing a client from head to toe, the Snellen chart would be used to assess distant vision before a stethoscope which would be used to auscultate heart, lung, and bowel sounds, and the carotid arteries for bruits. The tape measure would be used to measure circumference of limbs and the abdomen. The reflex hammer would be used to assess reflexes located on the extremities.
Which action by a nurse demonstrates the correct application of the principles of standard precautions? Wearing gloves when palpating the tongue, lips, & gums Using an antiseptic hand scrub to cleanse visibly soiled hands. Wearing a gown, gloves, and mask for the physical exam Change gloves after each body area is examined
Wearing gloves when palpating the tongue, lips, & gums Explanation: The nurse should wear gloves when examining or touching any areas where there is the potential for exposure to blood or body fluids. Gloves are changed between tasks and procedures on the same client after contact with material that may contain a high concentration of microorganisms. Wearing a gown, gloves, and mask is not necessary for the entire physical assessment. If hands are visibly soiled, the nurse should wash with soap and water.
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 light palpation. very deep palpation. moderate palpation. 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.
While examining a client, the nurse plans to palpate temperature of the skin by using the ulnar surface of the hand. dorsal surface of the hand. fingertips of the hand. palmar surface of the hand.
dorsal surface of the hand. Explanation: The dorsal surface of the hand is used to palpate body temperature.
A new graduate nurse is having trouble charting the details of a shift assessment on a client. The preceptor of the new nurse explains to the nurse that accurate descriptions are essential for legal documentation facilitating clear communication maximizing the efficiency of care setting the client's expectations
legal documentation Explanation: Accurate descriptions are essential for legal documentation and communication of findings.
The nurse is preparing the examination room before assessing a client. What is the purpose for a clean folded sheet on the examination table? serve as a head support collect body fluids pad the table use as a drape
use as a drape Explanation: During the examination, one body part should be exposed at a time. The sheet serves as a drape to keep the other body parts covered. The sheet is not used to pad the table, collect body fluids, or to be a head support.
What is the single most important method of preventing infection transmission by the nurse when coming into contact with a client? Wearing latex gloves Gowning Using eye protection Handwashing
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.
The admitting nurse has just met a new client. As the nurse introduces himself, he begins the process of inspection on this client. What does the admitting nurse know it is important to do while observing during the process of inspection? Gather as much general information as possible Pay attention to the details while observing Write down as many details as possible during the observation Not to let the client know he is being observed
Pay attention to the details while observing Explanation: It is essential to pay attention to the details in observation. Vague, general statements are not a substitute for specific descriptions based on careful observation. "Gather as much general information as possible" is incorrect because it is specific information, not general information, that is being gathered; "Write down as many details as possible during the observation" is incorrect because writing while observing can be a conflict for the nurse; "Not to let the client know he is being observed" is incorrect because it is not important to keep the client from knowing he is being observed.
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 flatness. tympany. hyperresonance. dullness.
hyperresonance. Explanation: Hyper-resonance is a sound heard when percussing over the lungs of a client with emphysema.
Light palpation is most appropriate to assess the inflamed areas of skin liver appendix bladder
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 (e.g., over an intravenous site).
A client has an enlarged area on the lower leg. Which technique should the nurse expect to use to assess this body area? palpation auscultation percussion inspection
palpation Explanation: Palpation is the use of touch to assess texture, temperature, moisture, size, shape, location, position, vibration, crepitus, tenderness, pain, and edema. Inspection is used to conduct the general survey, observing for body positioning, appearance, and behavior. Percussion is used to illicit sound or determine tenderness. Auscultation is used to listen to sounds.
Before beginning a physical assessment of a client, the nurse should first request a family member to be present. ask the client to remove all clothing. wash both hands with soap and water. determine whether the client is anxious.
wash both hands with soap and water. Explanation: A general principle to keep in mind while performing a physical assessment includes washing hands before beginning the examination. If possible, wash hands in the examining room in front of the client. This assures the client that you are concerned about his or her safety.
The nurse is conducting a physical examination on a client with a history of heart problems. Which technique would most likely provide the most information about the client's current cardiac status? palpation auscultation percussion inspection
auscultation Explanation: Auscultation is used to listen to sounds. Because the client has a history of heart problems, the heart sounds will provide the most information. Palpation is the use of touch to assess texture, temperature, moisture, size, shape, location, position, vibration, crepitus, tenderness, pain, and edema. Inspection is used to conduct the general survey, observing for body positioning, appearance, and behavior. Percussion is used to illicit sound or determine tenderness.
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 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 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 Ophthalmoscope Opaque card Penlight
Snellen chart Explanation: To check the client's distant vision the nurse should use the Snellen chart. An ophthalmoscope is used to view the red reflex and examine the retina of the eye. An opaque card is used to test for strabismus. A penlight is used to test pupillary constriction.
Which is an example of palpation? Select all that apply. The nurse detects a small mass in the epigastric area. The nurse detects increased warmth surrounding an abdominal incision. The nurse detects fruity odor of the client's breath. The nurse detects dullness over the liver. The nurse detects crepitus over the individual's thorax.
The nurse detects a small mass in the epigastric area. The nurse detects crepitus over the individual's thorax. The nurse detects increased warmth surrounding an abdominal incision. 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 client'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.
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 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.
When assessing pulses, the nurse would use which part of the hand for palpation? Dorsal surface Ulnar surface Palmar surface Finger pads
Finger pads Explanation: The finger pads are used for fine discrimination such as pulses, texture and size. The ulnar or palmar surface is used for vibrations, thrills and fremitus. The dorsal surface is used for temperature.
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? Femoral pulses Breath sounds Bowel sounds Heart sounds
Heart sounds Explanation: The bell of the stethoscope is used to listen to low-pitched sounds such as abnormal heart sounds (heart murmurs) and bruits. The diaphragm is used to listen for high-pitched sounds such as normal heart sounds, breath sounds, bowel sounds, and pulses.
When conducting a health assessment, it is sometimes necessary to conduct specific physical assessments that use specialized tools. What are some of these special tools? Select all that apply. Goniometer Stethoscope Skin-fold calipers Glasses Ophthalmoscope
Ophthalmoscope Goniometer Skin-fold calipers Explanation: Some physical assessment techniques require special equipment. Examples of special tools include an ophthalmoscope, visual acuity chart, otoscope, tuning fork, percussion hammer, vaginal speculum, goniometer, and skin-fold calipers. Glasses and a stethoscope are not considered specialized tools.
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? Tongue depressor Penlight Tuning fork Otoscope
Tuning fork Explanation: A tuning fork is needed to assess air and bone sound conduction. A penlight would be used to assess pupil reaction and inspect a client's mouth and throat. A tongue depressor would be used to view the throat and cheeks, and check the strength of the client's tongue. An otoscope would be used to view the ear canal and tympanic membrane.
Light palpation is most appropriate to assess the appendix inflamed areas of skin liver bladder
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 (e.g., over an intravenous site).
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 hand rub Hand wash with antiseptic soap Nonantimicrobial soap and water with friction No washing is needed because hands are not soiled
Application of an antiseptic hand rub Explanation: The nurse could apply an antiseptic hand rub 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.
A nurse needs to auscultate the heart sounds of a client who is in a hospital room watching his favorite television show. Before beginning the assessment, which of the following should the nurse do to provide a proper environment for the assessment? Turn off the TV and begin the assessment. Leave the television as is, as the client is enjoying his show and being distracted from his pain. Ask the client if it would be okay to mute the volume on the TV during the assessment. Ask the client to play some music from his laptop computer instead of watching TV.
Ask the client if it would be okay to mute the volume on the TV during the assessment. Explanation: To perform a physical examination, the nurse needs a quiet area free from distractions, such as a television, music, or other noisy equipment. Moreover, auscultation in particular requires a quiet environment so that the nurse can hear the client's heart or breath sounds without competing noises. Thus, the nurse should not leave the television as is or ask the client to listen to music on his laptop. Turning off the TV without asking the client first would be rude. Muting the television provides a quiet environment for the nurse to work in while also allowing the client to watch the show.
The nurse is planning to assess for the presence of lower pitch sounds when examining a client's heart. Which item of equipment would the nurse use to make this assessment? Diaphragm of a stethoscope Bell of a stethoscope Two test tubes Tuning fork
Bell of a stethoscope Explanation: The bell of the stethoscope transmits lower pitched sounds. A tuning fork is used to assess hearing and not lower pitch sounds. Test tubes are not used to assess sound. The diaphragm of the stethoscope is used to assess higher pitch sounds.
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? Reflex (percussion) hammer Penlight Braden scale Snellen E chart
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 begins her examination of a client with a skin disorder by using inspection techniques. Which skin characteristics can the nurse observe by using inspection? Texture Temperature Color Elasticity
Color Explanation: Inspection involves using the senses of vision, smell, and hearing to observe and detect normal or abnormal findings. Therefore, the nurse can observe the client's skin color using the physical assessment technique of inspection. Assessing skin temperature, texture, and elasticity involve the physical assessment technique of palpation.
A nurse is appraising a colleague's assessment technique as part of a continuing education initiative. The nurse demonstrates the proper technique for light palpation by performing which action? Depressing the skin 1 to 2 centimeters with the dominant hand Placing the nondominant hand on top of the dominant hand Feeling the surface structures using a circular motion Using one hand to apply pressure and the other hand to feel the structure
Feeling the surface structures using a circular motion Explanation: Light palpation is demonstrated by placing the hand lightly on the surface of the structure using a circular motion to feel the structure. Depressing the skin 1 to 2 cm with the dominant hand below the nondominant hand (or nondominant hand placed on top of the dominant hand) is deep palpation. Using one hand to apply pressure and the other to feel the structure reflects bimanual palpation
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, gown Mask, protective eye goggles, gown Mask, protective eye goggles Gloves, mask, protective eye goggles, gown
Gloves, mask, protective eye goggles, gown Explanation: Because this client has emphysema with a chronic productive cough, it is likely that the nurse will not only come into direct contact with the client's sputum or mucus (a body fluid) during examination of his oral cavity, which requires the use of gloves, but also that sputum will be sprayed on the nurse's face and body, which requires the use of a mask, protective eye goggles, and a gown.
The nurse would use the tuning fork to assess for what? Eye movement Visualization Hearing loss Reflexes
Hearing loss Explanation: The tuning fork is used to assess for hearing loss. Reflexes may be checked with a reflex hammer. An ophthalmoscope is used for the eye. An ophthalmoscope and otoscope are used for visualization.
A client who reports having a burning rash in the perianal area says, "Just stop asking questions and look at the rash right now." Which response by the nurse is best?
I just need to gather more information about your symptoms to help you the best way I can. Explanation: The collection of subjective information during history taking assists the nurse in focusing the examination accordingly. Conducting a thorough health history prior to a physical examination of the rash ensures that that nurse has not missed any clues that may uncover an underlying cause to the chief report. Looking at the rash immediately may cause the health history to be rushed and risk completing the assessment in a less thorough manner. It is within the nurse's scope of practice to assess the affected area and engage in the nursing process to manage the client's care. Both the subjective data obtained from the health history and the physical examination come together to ensure a comprehensive client assessment.
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? Auscultation, percussion, palpation, inspection Palpation, inspection, auscultation, percussion Percussion, palpation, inspection, auscultation Inspection, palpation, percussion, auscultation
Inspection, palpation, percussion, auscultation Explanation: Four basic techniques must be mastered before you can perform a thorough and complete assessment of the client. These techniques are inspection, palpation, percussion, and auscultation. Inspection precedes palpation, percussion, and auscultation because the latter techniques can potentially alter the appearance of what is being inspected.
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. Allow the client to undress and put on a gown. Auscultate all necessary body systems to prevent disturbing any organs. Begin at the head and move in a systematic approach.
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 and 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.
Which of the following should the nurse do before conducting a physical examination of a client? (Select all that apply.) Wash hands. Identify ways to ensure client privacy. Obtain and check needed equipment. Dim the lighting to promote comfort Turn on relaxing music of the client's choice
Obtain and check needed equipment. Identify ways to ensure client privacy. Wash hands. Explanation: Prior to conducting a physical examination of a client, the nurse should obtain and check needed equipment, identify how to maintain client 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.
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? Palmar surface Dorsal surface Fingertips Finger pads
Palmar surface Explanation: 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 finger pads are used to detect fine discriminations, such as pulses, texture, size, consistency, shape, and crepitus.
Which of the following is a component of the general survey? Patient's breath sounds Patient's oral temperature Patient's state of hygiene Patient's blood pressure
Patient's state of hygiene Explanation: During the general survey, the nurse should note the client's general state of health, build, and sexual development. Note posture, motor activity, and gait; dress, grooming, and personal hygiene; and any odors of the body or breath. Watch the client's facial expressions and note manner, affect, and reactions to people and things in the environment. Listen to the client's manner of speaking and note the state of awareness or level of consciousness. Measure height and weight.
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? Sphygmomanometer Metric ruler Platform scale with height attachment Skinfold calipers
Skinfold calipers Explanation: Skinfold calipers measure skinfold thickness of subcutaneous tissue to aid in establishing a client's percent body fat. A platform scale with height attachment measures height and weight. A metric ruler is used to measure the size of skin lesions. A sphygmomanometer, in conjunction with a stethoscope, is used to measure diastolic and systolic blood pressure.
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? Auscultation can be performed through clothing. The binaurals connect the tubing to the chest piece. The diaphragm should be held firmly against the body part. The bell of the stethoscope can detect bowel sounds.
The diaphragm should be held firmly against the body part. Explanation: The diaphragm should be held firmly against the body part being examined. Auscultation should not be performed through clothing because it may obscure or alter sounds. The bell detects low-pitched sounds such as murmurs and bruits. The binaurals are the metal tubing that connects the ear pieces to the tubing.
Which illustrates the nurse using the technique of inspection? The nurse detects tympany over the client's lower abdomen. The nurse detects a fruity odor of the client's breath. The nurse notes a rhythmic lub-dub over the client's anterior thorax. The nurse notes increased warmth surrounding the client's incision.
The nurse detects a fruity odor of the client's breath. Explanation: Inspection involves conscious observation of the client's physical characteristics and behaviors and smelling for odors. The nurse uses the technique of inspection to detect a fruity odor to the client's breath. The nurse uses the technique of palpation to note increased warmth surrounding an incision. Auscultation is used by the nurse to assess the lub-dub sounds of the heart. The nurse detects tympanic sounds of the bowel by percussing the abdomen.
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. Explanation: Some positions may be very difficult or impossible for the older client to assume or maintain because of decreased joint mobility and flexibility. The nurse cannot omit intrusive parts of the exam or allow the client to remain dressed because essential information may be missed. The nurse can approach the client slowly, allow for rest periods, and provide clear explanations to the older adult client to help facilitate the exam and decrease anxiety. Dimming the lights would interfere with the nurse's ability to inspect the client.
The nurse prepares to use mediate percussion to assess lung tissue. Which action will the nurse take when using this assessment technique? Place one hand flat on the body area Tap directly over the lung tissue Use the middle finger to deliver two taps Make a fist with one hand
Use the middle finger to deliver two taps Explanation: Mediate or indirect percussion is the most commonly used method. When performing this technique, the middle finger of one hand is placed over the body part to be assessed while the middle finger of the other hand is used to strike the other hand, and deliver two quick taps. A fist with one hand and the other being flat on the body area is used for the blunt percussion technique. Tapping directly over the body part is used when performing direct percussion.
Which action by a nurse is appropriate before beginning a physical examination of a client? Remove gloves only after examination is over Approach the client from the left side of the examination table Wash hands before examination in the examination room Recap used needles and place in puncture-resistant containers
Wash hands before examination in the examination room Explanation: The nurse should wash hands before examination in the examination room in front of the client to ensure the client that his or her safety is first priority. To avoid injury, the nurse should not recap used needles, and all disposable needles and blades should be placed in puncture-resistant containers. The nurse should always approach the client from the right-hand side of the examination table, not the left-hand side, because most examination techniques are performed with the examiner's right hand. The nurse should change gloves if they become soiled at any time during the examination and apply new pair of clean or sterile gloves
The nurse is caring for the client who is receiving heparin. The nurse plans to: Wear a mask when administering heparin to the client Wear clean gloves when administering heparin to the client Perform hand hygiene with alcohol-based gel after administering the heparin Recap the needle after administering heparin to the client
Wear clean gloves when administering heparin to the client Explanation: Heparin is an anticoagulant administered subcutaneously in the abdomen, which may expose the nurse to direct contact with the client's body fluids. The nurse wears clean gloves when administering heparin and after administering the heparin does not recap the needle and performs hand hygiene with alcohol-based gel. A mask is not required when administering heparin to the client.
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 Application of firm pressure when using the bell Using the bell to detect high-pitched sounds Using the diaphragm to listen to low-pitched sounds
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.
The nurse is assessing a client's range of motion. Which equipment should the nurse use to validate the degrees of joint mobility? speculum test tubes stadiometer goniometer
goniometer Explanation: A goniometer is used to measure degree of flexion and extension of joints. A speculum is used to examine the ear canals. Test tubes are used to measure temperature sensation. A stadiometer is used to measure height.
While percussing an adult client during a physical examination, the nurse can expect to hear flatness over the client's abdomen. bone. lungs. liver.
bone. Explanation: Flatness is a sound heard over very dense tissue like bone.
The nurse selects a tuning fork to use when assessing a client. Which body system is the nurse most likely assessing? peripheral vascular respiratory gastrointestinal genitourinary
peripheral vascular Explanation: A tuning fork has two uses in the physical examination. The most common is to assess hearing however the tuning fork is also used to assess the sense of vibration when completing the neurologic or peripheral vascular assessment. A tuning fork is not used to assess the respiratory, genitourinary or gastrointestinal systems.
The nurse wears gloves for which of the following purposes? Select all that apply. Prevent transmission of flora from client to client. Increase the risk of the nurse acquiring infection from the client. Limit exposure to body fluids and secretions Facilitate contamination of the hands of the nurse.
peripheral vascular Explanation: A tuning fork has two uses in the physical examination. The most common is to assess hearing however the tuning fork is also used to assess the sense of vibration when completing the neurologic or peripheral vascular assessment. A tuning fork is not used to assess the respiratory, genitourinary or gastrointestinal systems.
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? scoliometer pulse oximeter penlight reflex hammer
reflex hammer Explanation: A reflex is used to assess deep tendon reflexes which are under the control of the neurologic system. A penlight is used to assess pupillary reflexes and aids with tangential lighting. A scoliometer measures the degree of spinal curvature. A pulse oximeter measures oxygen level.
To adhere to standard precautions, the nurse should remember to (Select all that apply.) wash hands before and after client contact change white coat frequently wear gloves with each client contact put on a cover gown when entering a client's room
wash hands before and after client contact change white coat frequently
