NURS 146 Ch.3

Universal precautions are primarily designed to protect the health care worker from what?

Blood-borne pathogens

A nurse is preparing to perform a test for stereognosis in a client. Which piece of equipment should the nurse use?

Coin or key

Which illustrates the nurse using the technique of inspection?

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

Which describes the nurse using the technique of auscultation?

The nurse detects gurgling throughout the abdomen.

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.

A nurse is preparing to physically examine a client. Which action is most important to take before beginning the examination?

Wash hands before examination in the examination room.

Before beginning a physical assessment of a client, the nurse should first

wash both hands with soap and water

What would be the expected tone elicited by percussion of a normal lung?

Resonance

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

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

The client is in a standing position. Which of the following can the nurse most effectively assess with the client in this position?

Balance

When assessing pulses, the nurse would use which part of the hand for palpation?

Finger pads

During the physical examination of your client you auscultate the sound of the client's breathing. What area of the client are you assessing?

Lungs

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

bone

Light palpation is most appropriate to assess the

inflamed areas of skin

A client asks why gloves are being worn during the physical examination. What should the nurse respond to this client?

"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?

Adequate lighting

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?

Resonance

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?

Skinfold calipers

Which action by a nurse demonstrates the correct application of the principles of standard precautions?

Wearing gloves when palpating the tongue, lips, & gums