Nurs 224 Chapter 3 CoursePoint

A nurse on an oncology unit enters a client's room to auscultate bowel sounds. What should the nurse do before auscultating? a) Disinfect the stethoscope before touching the client. b) Disinfect the stethoscope after touching the client. c) Make sure the stethoscope is placed directly on the client's skin so that there is complete contact with the skin surface. d) Put on a personal protection gown.

a) Disinfect the stethoscope before touching the client.

The nurse would use what part of the hand when assessing temperature during palpation? a) Dorsal surface b) Finger pads c) Ulnar surface d) Palmar surface

a) Dorsal surface

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? a) Heart sounds b) Bowel sounds c) Breath sounds d) Femoral pulses

a) Heart sounds

What physical assessment technique should a nurse use to obtain a pulse on a client? a) Light palpation b) Moderate palpation c) Deep palpation d) Bimanual palpation

a) Light palpation

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) Begin at the head and move in a systematic approach. c) Auscultation of all necessary body systems to prevent disturbing any organs. d) Allow the client to undress and put on a gown.

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

The nurse is completing a physical examination of a client who reports ear pain. In order to determine if the tympanic membrane is still intact, which instrument is required? a) Otoscope b) Sphygmomanometer c) Stethoscope d) Ophthalmoscope

a) Otoscope

The nurse wears gloves for which of the following purposes? Select all that apply. a) Prevent transmission of flora from client to client. b) Increase the risk of the nurse acquiring infection from the client. c) Limit exposure to body fluids and secretions. d) Facilitate contamination of the hands of the nurse.

a) Prevent transmission of flora from client to client. c) Limit exposure to body fluids and secretions.

Which describes the nurse using the technique of percussion? a) The nurse notes resonance over the individual's thorax. b) The nurse detects crepitus over the individual's thorax. c) The nurse notes symmetry of the individual's thorax. d) The nurse detects rustling over the individual's thorax.

a) The nurse notes resonance over the individual's thorax.

How should the nurse place the ear of an adult when using the otoscope? a) Up and back b) Down and back c) Up and forward d) Down and forward

a) Up and back

The nurse is caring for the client who is receiving heparin. The nurse plans to: a) Wear clean gloves when administering heparin to the client. b) Recap the needle after administering heparin to the client. c) Perform hand hygiene with alcohol-based gel after administering the heparin. d) Wear a mask when administering heparin to the client.

a) Wear clean gloves when administering heparin to the client.

While percussing an adult client during a physical examination, the nurse can expect to hear flatness over the client's a) Lungs b) Bone c) Liver d) Abdomen

b) Bone

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) Nasopharyngeal airway b) Gloves c) Gown d) Face shield e) Stethoscope

b) Gloves c) Gown d) Face shield

The nurse is percussing the area over the lungs and hears a loud, low pitched, hollow sound. The nurse documents this finding as which of the following? a) Flatness b) Resonance c) Tympany d) Dullness

b) Resonance

The nurse is preparing to auscultate sounds that have a lower pitch. Which equipment should be used to complete this assessment? a) Doppler b) Stethoscope bell c) Sphygmomanometer d) Stethoscope diaphragm

b) Stethoscope bell

The nurse is preparing the examination room before assessing a client. What is the purpose for a clean folded sheet on the examination table? a) Pad the table b) Use as a drape c) Collect body fluids d) Serve as a head support

b) 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? a) Nonantimicrobial soap and water with friction. b) Hand wash with antiseptic soap. c) Application of an alcohol-based hand rub. d) No washing is needed because hands are not soiled.

c) Application of an alcohol-based hand rub.

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? a) Tuning fork b) Two test tubes c) Bell of a stethoscope d) Diaphragm of a stethoscope

c) Bell of a stethoscope

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) Light palpation b) Moderate palpation c) Deep palpation d) Very deep palpation

c) Deep palpation

While performing the physical examination of a client, the nurse lightly taps certain parts of the body to produce sound waves. What is the purpose of this method of assessment? a) Feel for deep organs or structures covered by thick muscles. b) Determine tenderness, moisture, and the surface of skin texture. c) Determine if a structure is filled with air or fluid or is a solid structure. d) Observe for abnormalities on the skin's surface.

c) Determine if a structure is filled with air or fluid or is a solid structure.

The nurse is assessing a client's range of motion. Which equipment should the nurse use to validate the degrees of joint mobility? a) Speculum b) Test tubes c) Goniometer d) Stadiometer

c) Goniometer

Light palpation is most appropriate to assess the a) Appendix b) Bladder c) Inflamed areas of skin d) Liver

c) Inflamed areas of skin

What condition are clients who are frequently hospitalized, as well as nurses, more often diagnosed with than the general population? a) Bunions b) Inflamed skin c) Latex allergy d) Medication allergies

c) Latex allergy

You should use the bell of the stethoscope when auscultating what type of sounds? a) Abnormal sounds b) High-frequency sounds c) Low-frequency sounds d) Sounds that are partially audible without a stethoscope

c) Low-frequency sounds

As the density of tissue decreases, the percussion note becomes: a) Softer b) Shorter c) Lower pitched d) Less musical

c) Lower pitched

During the physical examination of your client you auscultate the sound of the client's breathing. What area of the client are you assessing? a) Abdomen b) Neck c) Lungs d) Back

c) Lungs

The nurse is using the finger pads of the hand to palpate a body part. The nurse would best be able to detect which finding? a) Temperature b) Vibrations c) Pulses d) Fremitus

c) Pulses

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? a) Penlight b) Scoliometer c) Reflex hammer d) Pulse oximeter

c) Reflex hammer

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? a) Mid-arm circumference b) Client's height c) Skin lesion size d) Pupillary size

c) Skin lesion size

The nurse is planning to assess a client from head to toe. Which equipment should the nurse prepare to use first? a) Stethoscope b) Tape measure c) Snellen chart d) Reflex hammer

c) Snellen chart

A nurse performing percussion over the area of the stomach should anticipate hearing which type of sound? a) Resonance b) Hyper-resonance c) Tympany d) Dullness

c) Tympany

A nurse is admitting a new client to the subacute medical unit and is completing a comprehensive assessment. The nurse is appropriately applying standard precautions by performing what action? a) Performing hand hygiene between examinations of each body part. b) Discarding in the trash can the safety pin that was used to assess sensory perception. c) Wearing gloves to palpate the tongue and buccal membranes. d) Wearing a gown, gloves, and mask during the physical exam.

c) Wearing gloves to palpate the tongue and buccal membranes.

Which action by a nurse demonstrates the correct application of the principles of standard precautions? a) Using an antiseptic hand scrub to cleanse visibly soiled hands. b) Wearing a gown, gloves, and mask for the physical exam. c) Wearing gloves when palpating the tongue, lips, & gums. d) Change gloves after each body area is examined.

c) Wearing gloves when palpating the tongue, lips, & gums.

An adult client visits a clinic and tells the nurse that she suspects she has urinary tract infection. To detect tenderness over the client's kidneys, the nurse should instruct the client that he or she will be performing a) Moderate palpation b) Deep palpation c) Indirect percussion d) Blunt percussion

d) Blunt percussion

A nurse is palpating a child's forehead for signs of fever. Which part of the hand should the nurse use? a) Finger pads b) Ulnar surface c) Palmar surface d) Dorsal surface

d) Dorsal surface

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) Application of firm pressure when using the bell. b) Using the diaphragm to listen to low-pitched sounds. c) Using the bell to detect high-pitched sounds. d) Ensuring that contact with the skin is maintained.

d) 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? a) Comply with the client's request and proceed with the rest of the examination. b) Insist that the client undress and allow her breasts to be examined, for her own good. c) Ask the physician to perform the examination. d) Explain the importance of the examination and the risks of breast cancer.

d) Explain the importance of the examination and the risks of breast cancer.

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) Breath d) Heart murmur

d) Heart murmur

In which order should a nurse implement the four physical assessment techniques when initiating a health assessment? a) Auscultation, percussion, palpation, inspection b) Percussion, palpation, inspection, auscultation c) Inspection, auscultation, percussion, palpation d) Inspection, palpation, percussion, auscultation

d) Inspection, palpation, percussion, auscultation

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. True/False

False