NR 206 Collecting Objective Data: The Physical Examination

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? Hand wash with antiseptic soap Application of an alcohol-based hand rub No washing is needed because hands are not soiled. Nonantimicrobial soap and water with friction

Application of an alcohol-based hand rub

A nurse conducts a focused assessment on a hospitalized client. Which objective finding(s) should the nurse document in the client's chart? Select all that apply. Client grimaces when dorsiflexing the right calf. Right calf appears red. Client reports pain 8 out of 10 (10 being worst pain) when ambulating. Right calf is warm to touch. Client states, "I stopped taking my daily aspirin a week ago."

Client grimaces when dorsiflexing the right calf. Right calf appears red. Right calf is warm to touch.

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

Dorsiflexion of the foot

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? Look and observe before touching the client. Compare appearance of symmetric body parts. Eliminate distracting noises from the environment. Use good lighting, preferably sunlight.

Eliminate distracting noises from the environment.

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? Ask the physician to perform the examination Insist that the client undress and allow her breasts to be examined, for her own good Comply with the client's request and proceed with the rest of the examination Explain the importance of the examination and the risks of breast cancer

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

A female client is reporting burning during urination. The client refuses to allow the nurse to perform a vaginal assessment. What is the best action of the nurse? Explain to the client why the assessment is important and the possibility of missing important findings. Respect the client's decision and do not press her on the issue. Inform the client that an assessment must be completed in order to provide treatment. Tell the client she may have a friend or family member stay with her during the assessment.

Explain to the client why the assessment is important and the possibility of missing important findings.

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 Palpation, inspection, auscultation, percussion Percussion, palpation, inspection, auscultation Auscultation, percussion, palpation, inspection

Inspection, palpation, percussion, auscultation

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? Deep Moderate Light Intermediate

Light

You should use the bell of the stethoscope when auscultating what type of sounds? High-frequency sounds Abnormal sounds Low-frequency sounds Sounds that are partially audible without a stethoscope

Low-frequency sounds

What included in personal protective equipment? Select all that apply. Mouth, nose, eye protection Gloves Gown Special linen Cleaning processes

Mouth, nose, eye protection Gloves Gown

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

Sinuses

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? Metric ruler Platform scale with height attachment Sphygmomanometer Skinfold calipers

Skinfold calipers

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

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

True or False: It is recommended that a left-handed examiner adopt a right-sided position.

True

The nurse is caring for the client who is receiving heparin. The nurse plans to: Wear a mask when administering heparin to the client Recap the needle after administering heparin to the client Wear clean gloves when administering heparin to the client Perform hand hygiene with alcohol-based gel after administering the heparin

Wear clean gloves when administering heparin to the patient

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? use of moderate palpation with gloves auscultation of the heart with the stethoscope bell auscultation of the heart using the stethoscope diaphragm use of light palpation with an ungloved hand to sense murmur

auscultation of the heart with the stethoscope bell

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

bone.

What can the nurse assess using percussion? Borders of the heart Movement of the diaphragm during expiration Strength of the pulse Rectal distension

borders of the heart

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

deep palpation

The nurse observes a student nurse performing a focused assessment on a client presenting with signs and symptoms of appendicitis. The nurse should intervene when the student nurse is observed performing which of the following actions on the client's abdomen? moderate palpation direct palpation deep palpation light palpation

deep palpation

The nurse would use what part of the hand when assessing temperature during palpation? Finger pads Ulnar surface Palmar surface Dorsal surface

dorsal surface

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

inflamed areas of skin

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

light palpation