NURS 224: Techniques of Assessment and Safety

A client who reports having a burning rash in the perianal area says, "Just stop asking questions and look at the rash right now." Which response by the nurse is best? a) "I just need to gather more information about your symptoms to help you the best way I can." b) "Let's just take a look at that problem right away." c) "I will let the primary care provider take a look at that first." d) "I don't need to see the rash; I just need you to tell me about it."

a) "I just need to gather more information about your symptoms to help you the best way I can."

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

a) Disinfect the stethoscope before touching the client

A female client is told that she needs a pelvic exam and Papanicolaou (Pap) smear. She says "Absolutely not! There's no way I'll let you do that to me!" Which response by the nurse would be most appropriate? a) Explain the importance of the pelvic exam and Pap smear, but respect the client's wishes and omit the exam. b) Tell the client that this is the only way she can be checked for cancer. c) Ask the client if she would prefer another practitioner to perform the exam. d) Proceed with the pelvic exam and document the client's protests in the health record.

a) Explain the importance of the pelvic exam and Pap smear, but respect the client's wishes and omit the exam.

In the course of performing a client's physical assessment, the nurse has changed from using the diaphragm of the stethoscope to using the bell. The nurse is most likely assessing which of the following? a) Heart sounds b) Bowel sounds c) Breath sounds d) Femoral pulses

a) Heart sounds

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

a) Light palpation

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? a) Measure the client's vital signs, height, and weight. b) Begin at the head and move in a systematic approach. c) Auscultate all necessary body systems to prevent disturbing any organs. d) Allow the client to undress and put on a gown.

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

A nurse often has the option to use an alcohol-based hand rub for hand hygiene, but proper technique is essential in its use. What is the proper technique for the use of an alcohol-based hand rub? a) Rub the hands and fingers until dry b) Rub only the palms of the hands c) Use when the hands are visibly soiled d) Dry the hands on available paper towels

a) Rub the hands and fingers until dry

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

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

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

a) The nurse detects gurgling throughout the abdomen.

Which describes the nurse using the technique of percussion? a) The nurse notes resonance over the individual's thorax. b) The nurse detects crepitus over the individual's thorax. c) The nurse notes symmetry of the individual's thorax. d) The nurse detects rustling over the individual's thorax.

a) The nurse notes resonance over the individual's thorax.

How should the nurse place the ear of an adult when using the otoscope? a) Up and back b) Down and back c) Up and forward d) Down and forward

a) Up and back

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

a) Wear clean gloves when administering heparin to the client

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) ophthalmoscope

a) otoscope

When performing a physical assessment on an older adult client, what should the nurse consider offering this client? a) A family member in the room b) An extra blanket c) A pillow d) Elevation of the head of the examination table

b) An extra blanket

Which of the following is a component of the general survey? a) Patient's blood pressure b) Patient's state of hygiene c) Patient's breath sounds d) Patient's oral temperature

b) Patient's state of hygiene

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? a) Auscultation can be performed through clothing. b) The diaphragm should be held firmly against the body part. c) The bell of the stethoscope can detect bowel sounds. d) The binaurals connect the tubing to the chest piece.

b) The diaphragm should be held firmly against the body part.

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

b) bone.

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

b) use as a drape

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

c) "They make sure that any microorganisms on my hands do not touch your skin."

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.

c) Application of an alcohol-based hand rub

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? a) Nonantimicrobial soap and water with friction b) Hand wash with antiseptic soap c) Application of an antiseptic hand rub d) No washing is needed because hands are not soiled

c) Application of an antiseptic hand rub

A nurse is preparing to perform a physical examination on a young man who appears anxious about the procedure. Which of the following should the nurse do to ease this client's anxiety? a) Have him urinate before the examination. b) Perform the genital assessment first to get it over with. c) Before performing each procedure, explain what it involves and its purpose. d) Have him undress and put on an examination gown.

c) Before performing each procedure, explain what it involves and its purpose.

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

c) Blood-borne pathogens

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

c) Dorsal surface

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

c) Low-frequency sounds

During the physical examination of your client you auscultate the sound of the client's breathing. What area of the client are you assessing? a) Abdomen b) Neck c) Lungs d) Back

c) Lungs

An instructor is teaching a student about the proper use of a stethoscope. The instructor determines the need for additional teaching when the student states which of the following? a) Plastic tubing should be longer than 3 feet. b) The bell is used after using the diaphragm. c) When using the bell, push on it lightly. d) A diaphragm picks up low-pitched sounds.

c) When using the bell, push on it lightly.

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 a) light palpation. b) moderate palpation. c) deep palpitation d) very deep palpation.

c) deep palpitation

Light palpation is most appropriate to assess the a) appendix b) bladder c) inflamed areas of skin d) liver

c) inflamed areas of skin

A client is experiencing weakness of the left side of the body. Which piece of equipment should the nurse use to determine if the client's neurologic system is intact? a) penlight b) scoliometer c) reflex hammer d) pulse oximeter

c) reflex hammer

A nurse is examining a child who is suspected of having bronchitis and is preparing to auscultate his chest with a stethoscope. Which of the following actions would demonstrate the correct technique for this procedure? a) Application of firm pressure when using the bell b) Using the diaphragm to listen to low-pitched sounds c) Using the bell to detect high-pitched sounds d) Ensuring that contact with the skin is maintained

d) Ensuring that contact with the skin is maintained

After completing the physical examination of a client who is 12 weeks pregnant, a new nurse leaves the room only to realize she forgot to complete an examination of the skin. What should the nurse do? a) Omit this part of the physical examination. b) Review the documented client history. c) Ask a colleague who saw the client earlier. d) Go back in to complete a physical examination of the skin.

d) Go back in to complete a physical examination of the skin.

In which order should a nurse implement the four physical assessment techniques when initiating a health assessment? a) Auscultation, percussion, palpation, inspection b) Percussion, palpation, inspection, auscultation c) Inspection, auscultation, percussion, palpation d) Inspection, palpation, percussion, auscultation

d) Inspection, palpation, percussion, auscultation

The nurse selects a tuning fork to use when assessing a client. Which body system is the nurse most likely assessing? a) respiratory b) genitourinary c) gastrointestinal d) peripheral vascular

d) peripheral vascular