Chapter 3- Prep U

The nurse understands that the preferred method of hand hygiene when hands are not visibly soiled is what? - Hand washing - Alcohol-based rub - Gloves - Use of lotions

- Alcohol-based rub

What is used to gauge central and peripheral nervous system disorders? - Strength of a reflex - Gait - Tuning fork - Heat and cold

- Strength of a reflex

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

- Wearing gloves when palpating the tongue, lips, & gums

While percussing an adult client during a physical examination, the nurse can expect to hear flatness over the client's - lungs. - bone. - liver. - abdomen.

- bone.

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 - d, b, a, e, c - a, c, b, d, e - c, e, b, d, a - d, e, b, a, c

- c, d, e, b, a

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 - light palpation. - moderate palpation. - deep palpation. - very deep palpation.

- deep palpation.

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

- Blood-borne pathogens

When inspecting structures such as the jugular venous pulse, what would be the best lighting to use? - Direct lighting - Tangential lighting - Diffuse lighting - Back lighting

- Tangential lighting

Which describes the nurse using the technique of auscultation? - The nurse detects gurgling throughout the abdomen. - The nurse detects foul odor of the urine. -The nurse notes a small nodule in the breast. - The nurse notes dullness over the liver.

- The nurse detects gurgling throughout the abdomen.

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? - Supine - Lithotomy - Standing - Prone

- Lithotomy

For which assessment would the nurse plan to use direct percussion? - Sinuses - Kidneys - Liver - Gallbladder

- Sinuses

A client has an enlarged area on the lower leg. Which technique should the nurse expect to use to assess this body area? - palpation - inspection - percussion - auscultation

- palpation

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

- Limit position changes as much as possible

A nurse in the community is completing manual blood pressure assessments at a recreation center. Which action should the nurse take to ensure the assessment is accurate? - Turn down the volume if the television or radio is on. - Turn down the lights in the room. - Ensure that the client is lying down. - Ask the client to take deep breaths.

- Turn down the volume if the television or radio is on.

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? - Inspection - Palpation - Percussion - Auscultation

- Palpation

What would be the expected tone elicited by percussion of a normal lung? - Resonance - Hyper-resonance - Tympany - Dullness

- Resonance

When assessing pulses, the nurse would use which part of the hand for palpation? - Finger pads - Ulnar surface - Palmar surface - Dorsal surface

- Finger pads

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 - Intermediate - Moderate - Deep

- Light

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

- Light palpation

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? - Hyper-resonance - Resonance - Tympany - Dullness

- Resonance

The most commonly used method of percussion is - direct percussion. - mild percussion. - indirect percussion. - blunt percussion.

- indirect percussion.

Light palpation is most appropriate to assess the - appendix - bladder - inflamed areas of skin - liver

- inflamed areas of skin

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? - otoscope - sphygmomanometer - stethoscope - ophthalmoscope

- otoscope

A client asks why gloves are being worn during the physical examination. What should the nurse respond to this client? - "It's a policy I have to follow." - "They help me feel your body parts under your skin better." - "They make sure that any microorganisms on my hands do not touch your skin." - "Since we don't know what's wrong with you, I wear gloves to make sure I don't get sick."

- "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? - Warm, comfortable room - Quiet area free of disturbance - Adequate lighting - Firm examination bed or table

- Adequate lighting

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? - Range of motion of the spine - Posterior chest excursion - Head and neck range of motion - Dorsiflexion of the foot

- Dorsiflexion of the foot

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. - Nasopharyngeal airway - Gloves - Gown - Face shield - Stethoscope

- Gloves - Gown - Face shield

The nurse is preparing for a physical examination of a client. What should the nurse do first? - Hand hygiene - Gather equipment - Palpitation - Auscultation

- Hand hygiene

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? - Bowel - Normal heart - Breath - Heart murmur

- Heart murmur

The student nurse is caring for a client with emphysema. What sound would the student nurse expect to hear when percussing the client's lungs? - Resonant - Tympanic - Hyperresonant - Flat

- Hyperresonant

During the physical examination of your client you auscultate the sound of the client's breathing. What area of the client are you assessing? - Abdomen - Neck - Lungs - Back

- Lungs

A nurse is preparing to physically examine a client. The nurse recognizes that it is best to begin the objective data collection with which procedure? - Measure the client's vital signs, height, and weight. - Begin at the head and move in a systematic approach. - Auscultate all necessary body systems to prevent disturbing any organs. - Allow the client to undress and put on a gown.

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

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

- Prevent transmission of flora from client to client. - Limit exposure to body fluids and secretions

The nurse is conducting a physical examination of the abdomen. What is the nurse's best action to ensure she can hear bowel sounds? - Percuss the region before auscultating. - Palpate the region before auscultating. - Assist the client to a sitting position. - Reduce all environmental noise.

- Reduce all environmental noise.

A nurse, new to the hospital, is attending orientation with the nurse educator. The educator is discussing the use of deep palpation when assessing a client. The nurse should be aware of what risk when using this assessment technique? - Risk for injury - Risk for infection - Risk for chronic pain - Risk for impaired skin integrity

- Risk for injury

A nurse is preparing to 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? - Platform scale with height attachment - Metric ruler - Sphygmomanometer - Skinfold calipers

- Skinfold calipers

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

- The nurse detects a fruity odor of the client's breath.

Which is an example of percussion? Select all that apply. - The nurse notes dullness over the client's liver. - The nurse notes resonance over the client's thorax. - The nurse notes tympany over the client's lower abdomen. - The nurse notes rustling over the client's thorax. - The nurse notes gurgling throughout the client's abdomen.

- The nurse notes dullness over the client's liver. - The nurse notes resonance over the client's thorax. - The nurse notes tympany over the client's lower abdomen.

Which describes the nurse using the technique of percussion? - The nurse notes resonance over the individual's thorax. - The nurse detects crepitus over the individual's thorax. - The nurse notes symmetry of the individual's thorax. - The nurse detects rustling over the individual's thorax.

- The nurse notes resonance over the individual's thorax.

What is the principle of percussion? - To assess the sound created by the body - To strike the abdominal wall with a soft object - To create sound over dead spaces in the body - To create vibration in a body wall

- To create vibration in a body wall

The nurse is admitting a client to the surgical unit. The nurse should begin the general survey at which point in the admission process? - After the physical examination is completed - When the demographic data has been documented - Upon meeting the client and family members - As soon as any visitors have left the room

- Upon meeting the client and family members

While examining a client, the nurse plans to palpate temperature of the skin by using the - fingertips of the hand. - ulnar surface of the hand. - dorsal surface of the hand. - palmar surface of the hand.

- dorsal surface of the hand.

During a comprehensive assessment of the lungs of an adult client with a diagnosis of emphysema, the nurse anticipates that during percussion the client will exhibit - hyperresonance. - tympany. - dullness. - flatness.

- hyperresonance.

The nurse is preparing the examination room before assessing a client. What is the purpose for a clean folded sheet on the examination table? - pad the table - use as a drape - collect body fluids - serve as a head support

- use as a drape