Ch 3 PrepU 3060

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

Alcohol-based rub

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 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?

Heart murmur - 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

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

Low-frequency sounds

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 - 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

The nurse wants to determine the presence of air, fluid or solid tissues in the lungs of a client with a cough. Which technique should the nurse use for this part of the examination?

percussion

While performing a physical examination on an older adult, the nurse should plan to

use minimal position changes.

The nurse is admitting a client to the surgical unit. The nurse should begin the general survey at which point in the admission process?

Upon meeting the client and family members

Which action by a nurse demonstrates the correct application of the principles of standard precautions?

Wearing gloves when palpating the tongue, lips, & gums

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 foot

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

A client asks why gloves are being worn during the physical examination. What should the nurse respond to this client?

"They make sure that any microorganisms on my hands do not touch your skin."

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

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

C, D, E, B, A - 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

As a nurse is assessing a client and asking her questions, the nurse notices that the client stops talking and looks up anxiously each time someone passes by in the hallway outside her hospital room. Which nursing intervention would most likely address the client's concern and promote enhanced communication in this situation?

Close the door to the client's room

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 - At times during the physical examination abnormalities may be discovered. Anything unusual or disturbing should be discussed with the clinical instructor prior to the student interpreting the finding, determining an intervention, or how to communicate the findings to the client

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

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

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

Finger pads

The nurse wants to elicit a sound from a client's abdomen. Which technique should the nurse use?

Indirect percussion - Indirect percussion ensures that the client does not receive direct strikes to the body part being examined. Direct percussion might be painful when assessing the abdomen. Percussion is not divided into direct and indirect approaches

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 - 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

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

Reduce all environmental noise

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

Resonance - Resonance is noted with a normal lung. Hyper-resonance is noted in a lung with emphysema. Tympany is heard over air. Dullness is noted over solid tissue

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 - 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

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

To determine whether a structure is filled with air or fluid or is a solid structure - The nurse uses the percussion technique while performing a physical examination to determine whether the underlying structure is filled with air or fluid or is a solid structure. Palpation technique is used to feel deep organs or structures covered by thick muscles and to determine tenderness, moisture, and surface skin texture. The nurse uses the inspection technique to look for abnormalities on the skin's surface

The nurse observes a student nurse performing a focused assessment on a client with a suspected heart murmur. The nurse determines accurate assessment technique is used when which of the following is observed?

auscultation of the heart with the stethoscope bell - The bell of the stethoscope is used to assess low pitched sounds such as heart murmurs. The bell should be held lightly directly against the skin. The diaphragm of the stethoscope is used to detect high-pitched sounds. It should be held firmly against the client's skin. Even though a thrill may be palpated due to turbulent blood flow, it would have to be a high-grade murmur; therefore, light and moderate palpation would not be used to assess a heart murmur

During a comprehensive assessment, the primary technique used by the nurse throughout the examination is

inspection - Inspection involves using the senses of vision, smell, and hearing to observe and detect any normal or abnormal findings. This technique is used from the moment that you meet the client and continues throughout the examination. Inspection precedes palpation, percussion, and auscultation because the latter techniques can potentially alter the appearance of what is being inspected