PrepU Ch.3

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 Ref: (ch.3 pg.38)

The nurse enters the room of a client and sees that visitors are present. What is the nurse's best action? A) Politely tell the visitors to leave B) State that the visiting hours are over C) Ask permission to talk to the client in front of visitors D) Make eye contact solely with the client

Ask permission to talk to the client in front of visitors

Universal precautions are primarily designed to protect the health care worker from what? A) STDs B) Musculoskeletal injuries C) Blood-borne pathogens D) Respiratory diseases

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. Ref: (ch.3 pg.36)

A nurse is palpating a child's forehead for signs of fever. Which part of the hand should the nurse use? A) Fingerpads B) Ulnar surface C) Palmar surface D) Dorsal surface

Dorsal surface Ref: (ch.3 pg.40)

When assessing pulses, the nurse would use which part of the hand for palpation? A) Fingerpads B) Ulnar surface C) Palmar surface D) Dorsal surface

Fingerpads Ref: (ch.3 pg.40)

What included in personal protective equipment? Select all that apply. A) Gloves B) Gown C) Mouth, nose, eye protection D) Special linen E) Cleaning processes

Gloves Gown Mouth, nose, eye protection Ref: (ch.3 pg.34)

Light palpation is most appropriate to assess the A) Appendix B) Bladder C) Inflammed areas of skin D) Liver

Inflammed 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). Ref: (ch.3 pg.40)

During a comprehensive assessment, the primary technique used by the nurse throughout the examination is A) Palpation B) Percussion C) Auscultation D) Inspection

Inspection Ref: (ch.3 pg.37)

Which of the following techniques are used in a physical assessment? Select all that apply. A) Inspection B) Palpation C) Auscultation D) Questioning E) Subjectivity

Inspection, Palpation, Auscultation Ref: (ch.3 pg.37)

A nurse needs to obtain a pulse on a client. Which physical assessment technique should the nurse use? A) Light palpation B) Moderate palpation C) Deep palpation D) Bimanual palpation

Light palpation Ref: (ch.3 pg.40)

Which is the priority for the nurse conducting a physical examination of a client with generalized muscle weakness? A) Limit position changes as much as possible B) Hand-washing throughout the exam C) Using alcohol swabs to clean the stethoscope D) Draping body areas that are not being assessed

Limit position changes as much as possible Ref: (ch.3 pg.40)

Which of the following should the nurse do before conducting a physical examination of a client? (Select all that apply.) A) Obtain and check needed equipment B) Turn on relaxing music of the client's choice C) Identify ways to ensure patient privacy D) Dim the lighting to promote comfort E) Wash hands

Obtain and check needed equipment Identify ways to ensure patient privacy Wash hands Ref: (ch.3 pg.33)

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? A) Snellen chart B) Ophthalmoscope C) Opaque card D) Penlight

Snellen chart Ref: (ch.3 pg.32)

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

Wearing gloves when palpating the tongue, lips, and gums Ref: (ch.3 pg.36)

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

Disinfect the stethoscope before touching the client Ref: (ch.3 pg.35)

While examining a client, the nurse plans to palpate temperature of the skin by using the A) Fingertips of the hand B) Ulnar surface of the hand C) Dorsal surface of the hand D) Palmar surface of the hand

Dorsal surface of the hand Ref: (ch.3 pg.40)

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? A) Supine B) Lithotomy C) Standing D) Prone

Lithotomy Ref: (ch.3 pg.40)

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

Low-frequency sounds Ref: (ch.3 pg.43)

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) Opthalmoscope

Otoscope Ref: (ch.3 pg.32)

Which illustrates the nurse using the technique of inspection? A) The nurse detects a fruity odor of the patient's breath B) The nurse notes increased warmth surrounding the patient's incision C) The nurse notes a rhythmic lub-dub over the patient's anterior thorax D) The nurse detects tympany over the patient's lower abdomen

The nurse detects a fruity odor of the patient's breath Ref: (ch.3 pg.37)

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? A) Warm comfortable room B) Quite area free of disturbance C) Adequate lighting D) Firm examination bed or table

Adequate lighting Ref: (ch.3 pg.33)

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

Application of an alcohol-based hand rub Explanation: 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. Ref: (ch.3 pg.34)

The nurse is preparing client teaching for an adult admitted to the hospital with bilateral pneumonia. What should the nurse know to include in this client teaching? A) Cover your nose and mouth with your hands when coughing or sneezing B) Dispose of tissues directly into trash cans C) Wash your hands before coming into contact with another person D) Take medicine when you cannot stop coughing

Dispose of tissues directly into trash cans Explanation: Clients and other people with symptoms of a respiratory infection are asked to cover their mouths/noses when coughing or sneezing, but not covering the nose and mouth with their hands. Additionally, clients should dispose of tissues directly into trash cans and perform hand hygiene after hands have been in contact with respiratory secretions. The nurse does not teach to use hands to cover the face when sneezing or coughing—the client should instead cough or sneeze into a sleeve. Washing hands before coming into contact with another person is not part of client teaching for a person with pneumonia. Taking medicine when you cannot stop coughing does not answer the question. Ref: (ch.3 pg.35)

A nurse is performing percussion on a client's back to assess the lungs, and hears a loud, low-pitched, hollow sound, indicating normal lungs. Which of the following describes this finding? A) Hyper-resonance B) Resonance C) Tympany D) Dullness

Resonance Ref: (ch.3 pg.42)