6001

A nurse is preparing to evaluate an elderly 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

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

What guidelines should the nurse keep in mind while performing auscultation?

Eliminate distracting noise from the environment

A client with an inability to read billboards while driving arrives at the health care facility for an eye examination. Which piece of equipment should the nurse use to check the client's distant vision?

Snellen Chart

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 handrub

Which of the following techniques are used in a physical assessment? Select all that apply.

auscultation inspection palpation

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

bone

Which of the following would be most important for the nurse to do immediately before beginning the physical exam?

collect necessary equipment essential to the exam

While performing the physical examination of a client, the nurse lightly taps certain parts of the body to produce sound waves. What is the purpose of this method of assessment?

determine if a structure is filled with air or fluid or is a solid structure

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

dorsal 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 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?

gloves, face shield, gown

What is included in PPE

gloves, gowns, masks, protective eyewear

A nurse will be performing a complete physical examination of a man who has emphysema with a chronic productive cough, including an assessment of his oral cavity. Which pieces of personal protective equipment should the nurse wear?

gloves, mask, protective eye goggles, gown

Light palpation is most appropriate to assess the

inflamed areas of the skin

During a comprehensive assessment, the primary technique used by the nurse throughout the examination is

inspection

In which order should a nurse implement the four physical assessment techniques when initiating a health assessment?

inspection, palpation, percussion, auscultation

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

latex allergy

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

light palpation

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

A nurse must assess a client's red reflex. Which piece of equipment will the nurse need for this?

ophthalmoscope

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

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

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

peripheral vascular

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

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?

reflex hammer

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 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

The nurse is preparing to auscultate sounds that have a lower pitch. Which equipment should be used to complete this assessment?

stethoscope bell

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 of the following statements most accurately provides the underlying rationale for the use of auscultation and percussion as assessment techniques?

the nature and elasticity of tissue and body structures influence sound

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

up and back

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

wear clean gloves when administering heparin to patient

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?

wear 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, and gums