chapter 2/3

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 nurse can 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, nonintact skin, or wound dressings, the nurse would be required to hand wash with nonantimicrobial soap and water, or antiseptic soap. (less)

A young adult client has come to the clinic for her scheduled Pap (Papanicolaou) test and pelvic examination. The nurse is implementing actions to help reduce a client's anxiety during the physical exam. Which of the following would be most appropriate?

Ensuring client's privacy by providing an examination gown The client is usually concerned about unnecessary body exposure. Explanation and reassurance that the nurse will protect the client's privacy decreases this anxiety. Providing a comfortable, warm room temperature is appropriate to prevent chilling, but is usually less important to the client than privacy. Arranging exam equipment on a bedside tray table if within the view of the client may add to the client's anxiety. However, arranging the exam equipment would facilitate organization. Explaining why standard precautions are being used may help alleviate some anxiety, but the client probably will not understand what standard precautions are. (less)

A female client is told that she needs a pelvic exam and Papanicolaou (Pap) smear. She says "Absolutely not! There's no way I'll let you do that to me!" Which response by the nurse would be most appropriate?

Explain the importance of the pelvic exam and Pap smear, but respect the client's wishes and omit the exam. The nurse should explain to the client the importance of the examination and the risk of missing important information if any part is omitted. However, whether or not to have the examination is the client's decision and must be respected.

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 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. (less)

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

Inspection Palpation Auscultation The four techniques of inspection, palpation, percussion, and auscultation form the basis for physical assessment. Subjectivity and questioning are distracters for this question.

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?

Light 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. (less)

A nurse must assess a client's red reflex. Which piece of equipment will the nurse need for this?

Ophthalmoscope 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. (less)

As the density of tissue decreases, the percussion note becomes:

Shorter Low density tissue tends to produce sound that is lower pitched, musical, loud, and longer in duration than in denser tissue.

A nurse is preparing 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 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. (less)

The nurse is preparing to perform a physical examination on a female client who has been transferred to the medical unit from the emergency department. The nurse should begin the collection of objective data with which of the following examinations?

Vital signs The nurse should begin the examination with the less intrusive procedures, such as vital signs, first. Doing so allows the client to feel more comfortable with the nurse and helps to ease client anxiety about the examination. (less)