PrepU Chapter 3: Techniques of Assessment and Safety

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

When performing a physical assessment on an older adult client, what should the nurse consider offering this client?

An extra blanket

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?

Application of an antiseptic hand rub

The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure. The UAP is holding the cuff around the client's arm to prevent it from coming off while inflating. What is the best action of the nurse?

Ask the UAP to obtain a larger cuff for the client.

The nurse is planning to assess for the presence of lower pitch sounds when examining a client's heart. Which item of equipment would the nurse use to make this assessment?

Bell of a stethoscope

A health care provider is performing a comprehensive physical examination of a 51-year-old man. After performing a digital-rectal exam for prostate enlargement and tenderness, the nurse checks the fecal material on the gloved finger for the presence of which of the following?

Blood

A nurse is performing a comprehensive physical examination on a 51-year-old client with the chief report of middle back pain radiating to each side. The nurse suspects the kidneys may be inflamed. Which examination technique would be the most appropriate for the nurse to use?

Blunt percussion

A nurse on an oncology unit enters a client's room to auscultate bowel sounds. What should the nurse do before auscultating?

Disinfect the stethoscope before touching the client

When assessing the temperature of the feet of an older client with diabetes, the nurse would use which part of the hand to obtain the most accurate information?

Dorsal hand surface

What action by a nurse demonstrates the correct technique when using a stethoscope for auscultation?

Ensure that contact with the skin is maintained

A young adult client has come to the clinic for her scheduled Pap (Papanicolaou) test and pelvic examination. The nurse would implement which action to help reduce the client's anxiety during the physical exam?

Ensuring client's privacy by providing an examination gown

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

Finger pads

The nurse is to collect a throat culture from a client. The nurse demonstrates the best adherence to standard precautions by using which piece of protective equipment?

Gloves

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 student nurse is caring for a client with emphysema. What sound would the student nurse expect to hear when percussing the client's lungs?

Hyperresonant

What condition are clients who are frequently hospitalized, as well as nurses, more often diagnosed with than the general population?

Latex allergy

What physical assessment technique should a nurse use to obtain a pulse on a client?

Light palpation

A nurse performs indirect palpation of an underlying structure correctly when the hands are placed in which position?

Middle finger of one hand is placed on the body surface and the other middle finger strikes

Which of the following should the nurse do before conducting a physical examination of a client? (Select all that apply.)

Obtain and check needed equipment. Identify ways to ensure client privacy. Wash hands.

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

Which of the following is a component of the general survey?

Patient's state of hygiene

A nursing 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?

Plastic tubing should be longer than 3 feet.

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

The nurse is percussing the area over the lungs and hears a loud, low pitched, hollow sound. The nurse documents this finding as which of the following?

Resonance

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

Resonance

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?

Rub the hands and fingers until dry

A nurse has gathered the necessary equipment for the physical assessment of an adult client. It would be most appropriate for a nurse to use a centimeter-scale ruler for which measurement?

Skin lesion size

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?

The diaphragm should be held firmly against the body part.

Which describes the nurse using the technique of percussion?

The nurse notes resonance over the individual's thorax.

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

Wear clean gloves when administering heparin to the client

A nurse is admitting a new client to the subacute medical unit and is completing a comprehensive assessment. The nurse is appropriately applying standard precautions by performing what action?

Wearing gloves to palpate the tongue and buccal membranes

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

Wearing gloves when palpating the tongue, lips, & gums

Identify the steps in order of priority the nurse takes for performing hand hygiene, from first step to last. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left.

Wet the hands. Apply soap. Scrub the hands together vigorously for 15 seconds. Rinse the hands. Dry hands Turn off faucet with paper towel.

When the nurse places one hand flat on the body surface and uses the fist of the other hand to strike the back of the hand flat on the body surface, the nurse is using

blunt percussion.

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

bone.

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.

The nurse is assessing a client's range of motion. Which equipment should the nurse use to validate the degrees of joint mobility?

goniometer

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.

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

palpation

The nurse selects a tuning fork to use when assessing a client. Which body system is the nurse most likely assessing?

peripheral vascular