prep U: ch 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, 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 handrub

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

Determine if a structure is filled with air or fluid or is a solid structure

When conducting a health assessment, it is sometimes necessary to use special tools. What are some of these special tools? Select all that apply.

Ophthalmoscope Goniometer Skin-fold calipers 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 would not qualify as special too

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?

The diaphragm should be held firmly against the body part.

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?

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

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 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 he environment

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?

resonance A loud, low-pitched hollow sound on percussion is termed resonance and is a typical finding over the lungs, which are part air and part solid tissue. Flatness is a soft, high flat sound typically heard over very dense tissue. Tympany is a loud, high-pitched drum like sound heart over air filled areas. Dullness is a medium, medium-pitched thud like sound heard over more solid tissue.

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 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?

skin lesion size

The nurse is preparing to auscultate sounds that have a lower pitch. Which equipment should be used to complete this assessment?

bell of the stethoscope The bell of the stethoscope is used to auscultate low-pitched sounds. Doppler is used to detect pulses and blood flow. A sphygmomanometer is used to measure blood pressure. The diaphragm of the stethoscope is used to auscultate high-pitched sounds.

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 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.

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?

inspection, palpation, percussion, auscultation

A new graduate nurse is having trouble charting the details of a shift assessment on a patient. The preceptor of the new nurse explains to the nurse that accurate descriptions are essential for

legal documentation

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?

lithomy