PrepU Chapter 3

When is it necessary for a nurse to change gloves? Select all that apply.

The nurse changes gloves (1) between tasks and procedures on the same client after contact with material that contains a high concentration of microorganisms and (2) when going from a contaminated area to a cleaner area. Gloves are removed promptly after use, before touching noncontaminated items and environmental surfaces and before going to another client.

Which illustrates the nurse using the technique of inspection?

The nurse detects a fruity odor of the client's breath. Inspection involves conscious observation of the client's physical characteristics and behaviors and smelling for odors. The nurse uses the technique of inspection to detect a fruity odor to the client's breath. The nurse uses the technique of palpation to note increased warmth surrounding an incision. Auscultation is used by the nurse to assess the lub-dub sounds of the heart. The nurse detects tympanic sounds of the bowel by percussing the abdomen.

Which describes the nurse using the technique of percussion?

The nurse notes resonance over the individual's thorax. The nurse uses the technique of percussion to produce sounds over various parts of the body. The nurse detects resonance over the lungs by percussing the thorax. Inspection involves smelling for odors and conscious observation of the client's physical characteristics and behaviors, such as noting symmetry of the thorax. The nurse uses palpation to detect crepitus over the thorax by the use of touch. Auscultation is used by the nurse to assess lung sounds, such as rustling.

Which is an example of palpation? Select all that apply.

The nurse uses the technique of percussion to produce sounds over various parts of the body. The nurse detects resonance over the lungs by percussing the thorax. Inspection involves smelling for odors and conscious observation of the client's physical characteristics and behaviors, such as noting symmetry of the thorax. The nurse uses palpation to detect crepitus over the thorax by the use of touch. Auscultation is used by the nurse to assess lung sounds, such as rustling.

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 is the best response by the nurse?

"I need to gather more information about your symptoms to help you." The collection of subjective information during history taking assists the nurse in focusing the examination accordingly. Conducting a thorough health history prior to a physical examination of the rash ensures that that nurse has not missed any clues that may uncover an underlying cause to the chief report. Looking at the rash immediately may cause the health history to be rushed and risk completing the assessment in a less thorough manner. It is within the nurse's scope of practice to assess the affected area and engage in the nursing process to manage the client's care. Both the subjective data obtained from the health history and the physical examination come together to ensure a comprehensive client assessment.

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?

Application of an alcohol-based hand rub 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.

The nurse is conducting a physical examination of a client. After completing the examination, the nurse realizes that part of the examination was omitted by mistake. How should the nurse proceed?

Complete the forgotten portion of the exam out of sequence. The nurse should complete the forgotten portion of the exam out of sequence. It is not appropriate to proceed without complete assessment data, and collecting the missing data at the end of the shift is not part of a timely assessment. This initial assessment provides baseline data for comparison during the remainder of the shift. Informing the client that the examination was incomplete and starting over from the beginning of the assessment is not necessary.

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?

Eliminate distracting noises from the environment. The auscultation technique requires the use of a stethoscope. The nurse should eliminate any distracting or competing noises from the environment to ensure that the sounds heard are those of the client and not the environment. Using good lighting, preferably sunlight, looking and observing before touching the client, and comparing the appearance of symmetric body parts are some of the guidelines to perform the technique of inspection.

Equipment used in conducting a physical examination includes a gauze pad. What is this used for?

Examining the tongue Gauze pads are used during tongue examination. An applicator or tongue blade might be used to help invert the eyelid.

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.

The specific personal protective equipment needed to prevent the transmission of infectious agents varies depending on the procedure to be performed. For example, performing venipuncture requires only gloves, but intubation requires gloves, gown, and face shield, mask, or goggles. A nasopharyngeal airway may be needed for intubation, but its purpose is not to prevent transmission of infectious agents. A stethoscope would not be needed for this procedure.

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. When completing a manual blood pressure assessment, it is important to ensure that external noise does prevent the nurse's ability to hear the systolic and diastolic blood pressure sounds. Turning the television volume down assists the nurse in obtaining a more accurate measurement of the blood pressure. Turning down the lights in the room could prevent the nurse from being able to read the blood pressure accurately. The client may sit or lie down; having the client lie down is not necessary for an accurate reading. Asking the client to take deep breaths would promote relaxation; however, it would not improve the accuracy of the assessment.

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 Adequate lighting is most important for the physical examination of the client with scabies. Sunlight (when available) would be preferable; however, even a portable lamp or a good overhead light is sufficient for illuminating the skin and for viewing shadows and contours. A warm and comfortable room, a quiet area free of disturbance, and a firm examination bed or table are subsequent preparations to the physical setting for the examination.

A client is experiencing periodic abdominal pain. Which technique should the nurse plan to use immediately after inspecting the area?

auscultation During the abdominal examination, the pattern will be inspection, auscultation, percussion, and palpation. Auscultation follows inspection so as not to increase bowel motility with palpation.

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?

auscultation of the heart with the stethoscope bell The bell of the stethoscope is used to assess low pitched sounds such as heart murmurs. The bell should be held lightly directly against the skin. The diaphragm of the stethoscope is used to detect high-pitched sounds. It should be held firmly against the client's skin. Even though a thrill may be palpated due to turbulent blood flow, it would have to be a high-grade murmur; therefore, light and moderate palpation would not be used to assess a heart murmur.

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

balance The standing position is used to assess a client's balance in addition to spine range of motion, and visual acuity. The cervical spine and axillary nodes are assessed with the client in the seated position. The thorax is assessed in either the sitting or lying position.

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

blood-borne pathogens 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.

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

bone Flatness is a sound heard over very dense tissue like bone.

A nurse is preparing to evaluate an older client's risk for developing pressure sores after a 2-week stay in the hospital. Which of the following pieces of equipment will this nurse need for this purpose?

braden scale The Braden scale for predicting pressure sore risk would be the appropriate tool for evaluating a client's risk for developing pressure sores. The Snellen E chart is used to test distant vision. The penlight is used to view the mouth and throat and to transilluminate the sinuses. The reflex (percussion) hammer is used to test tendon reflexes.

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 anklesb. Groin, hips, and kneesc. Breastsd. Chest and thoraxe. Cardiovascular

c, d, e, b, a When conducting a head-to-toe assessment for a client in the lying position, the nurse should begin with the structures closest to the head and progress downward. The nurse will assess the breasts, the chest and thorax, the cardiovascular system, the groin, hips, and knees, and then the shins and ankles.

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?

deep palpation Deep or bimanual palpation is contraindicated in clients presenting with signs and symptoms of appendicitis, enlarged spleen, or abdominal aortic aneurysm (AAA). Deep palpation may cause rupture of the organ or artery. Moderate palpation should be performed; the client will most likely present with rebound tenderness. Light palpation may be performed to assess rigidity and warmth. Direct percussion is performed to produce sound or elicit pain to assess underlying structures, for example, sinuses and the thorax.

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

deep palpation Deep palpation depresses the surface between 2.5 and 5 cm (1 and 2 inches). This allows you to feel very deep organs or structures that are covered by thick muscle.

A nurse is palpating a child's forehead for signs of fever. Which part of the hand should the nurse use?

dorsal surface The dorsal (back) surface of the hand is the part most sensitive to temperature and thus is the correct part to use when palpating for temperature. The finger pads are for fine discriminations, such as for palpating for pulses, texture, size, consistency, shape, and crepitus. The ulnar or palmar surface is used to palpate for vibrations, thrills, and fremitus.

What is the single most important method of preventing infection transmission by the nurse when coming into contact with a client?

handwashing Contact transmission from the hands of all health care providers to clients is the most common mode of transmission, because microorganisms from one client are then spread to others. Wearing latex gloves is one step in preventing infection transmission but not the most important. Using eye protection and gowning are important in certain infection transmission situations, but again, not the most important.

The nurse would use the tuning fork to assess for what?

hearing loss The tuning fork is used to assess for hearing loss. Reflexes may be checked with a reflex hammer. An ophthalmoscope is used for the eye. An ophthalmoscope and otoscope are used for visualization.

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?

heart murmur The bell of the stethoscope is used to listen for low pitched sounds such as abnormal heart sounds or bruits. The diaphragm is used to listen for high pitched sounds such as normal heart, lung, & bowel sounds.

A nurse needs to obtain a pulse on a client. Which physical assessment technique should the nurse use?

light palpation The nurse should use the light palpation technique to check the pulse of the client. Moderate and bimanual palpations are used to note the size, consistency, and mobility of the structures that are palpated. Deep palpation enables the nurse to feel very deep organs or structures that are covered by thick muscles.

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

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?

lithotomy The lithotomy position is used to examine the female genitalia, reproductive tracts, and the rectum. It involves the client lying on her back with the hips at the edge of the examination table and the feet supported by stirrups. In the supine position, the client lies down with the legs together on the examination table. This position allows the abdominal muscles to relax and provides easy access to peripheral pulse sites. Areas assessed with the client in this position may include the head, neck, chest, breasts, axillae, abdomen, heart, lungs, and all extremities. In the standing position, the client stands still in a normal, comfortable, resting posture. This position allows the examiner to assess posture, balance, and gait. This position is also used for examining the male genitalia. In the prone position, the client lies down on the abdomen with the head to the side. The prone position is used primarily to assess the hip joint.

You should use the bell of the stethoscope when auscultating what type of sounds?

low-frequency sounds The bell is used with light skin contact to hear 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?

lungs

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 nurse needs an otoscope to visualize the tympanic membrane and the inner ear. The nurse would need a sphygmomanometer to assess the client's blood pressure. The nurse would need a stethoscope to auscultate the lungs and abdomen. The nurse would need an ophthalmoscope to visualize the retina of the eye.

A nurse is palpating a client's chest for vibration as he inhales and exhales. Which part of the hand should the nurse use in this case?

palmar surface The ulnar-or palmar-surface is the part of the hand used to palpate vibrations. The fingertips are not used to palpate. The dorsal surface is sensitive to temperature and the finger pads are used to detect fine discriminations, such as pulses, texture, size, consistency, shape, and crepitus.

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?

palpation

You are performing a shift assessment as you begin caring for one of your clients. What is the most effective assessment technique for the lymph nodes of the neck?

palpation Palpation is a part of the assessment that allows the nurse to assess a body part through touch. Many structures of the body (superficial blood vessels, lymph nodes, thyroid gland, organs of the abdomen, pelvis, and rectum), although not visible, may be assessed through the techniques of light and deep palpation. The other options are incorrect because lymph nodes are not assessed through inspection, auscultation, or percussion.

The nurse is having difficulty visualizing the apical impulse during a physical examination of the cardiovascular system. Which assessment tool is required for a more accurate assessment?

penlight

The nurse is conducting a physical examination of the abdomen. What is the nurse's best action to ensure she can hear bowel sounds?

reduce all environmental noise Auscultating bowel sounds can be difficult because of environmental noise. The nurse should reduce all environmental noise and auscultate the bowel sounds again. The steps used to assess the abdomen are inspection, auscultation, percussion, and palpation. The techniques of percussion and palpation will cause the client to experience bowel sounds and, therefore, should be performed after bowel sounds are auscultated. Assessment of the abdomen is best performed with the client in the lying position.

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

resonance Resonance is noted with a normal lung. Hyper-resonance is noted in a lung with emphysema. Tympany is heard over air. Dullness is noted over solid tissue.

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 Skinfold calipers measure skinfold thickness of subcutaneous tissue to aid in establishing a client's percent body fat. A platform scale with height attachment measures height and weight. A metric ruler is used to measure the size of skin lesions. A sphygmomanometer, in conjunction with a stethoscope, is used to measure diastolic and systolic blood pressure.

What is used to gauge central and peripheral nervous system disorders?

strength of a reflex

How should the nurse place the ear of an adult when using the otoscope?

up and back

The nurse is admitting a client to the surgical unit. The nurse should begin the general survey at which point in the admission process?

upon meeting the client and family members

The nurse is caring for the client who is receiving heparin. The nurse plans to:

wear clean gloves when administering heparin to the client Heparin is an anticoagulant administered subcutaneously in the abdomen, which may expose the nurse to direct contact with the client's body fluids. The nurse wears clean gloves when administering heparin and after administering the heparin does not recap the needle and performs hand hygiene with alcohol-based gel. A mask is not required when administering heparin to the client.