Health Assessment Ch 3

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.

- Gloves - Gown - Face shield

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

- Inspection - Palpation - Auscultation - Percussion

The nurse wears gloves for which of the following purposes? Select all that apply.

- Prevent transmission of flora from client to client. - Limit exposure to body fluids and secretions

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

- The nurse notes gurgling sounds over the individual's abdomen. - The nurse notes crackling over the individual's thorax. - The nurse notes a rhythmic lub-dub over the client's anterior thorax.

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

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 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?

Ensuring that contact with the skin is maintained

The nurse is preparing for a physical examination of a client. What should the nurse do first?

Hand hygiene

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 nurse is assessing a client with unexplained lesions noted on the client's back. The nurse is going to palpate the area of the lesions. What type of palpation should the nurse use?

Light

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

Light palpation

The nurse is performing percussion over the lung fields. The nurse hears a dull tone in the lower lung fields, which is a new finding. What is the next best action of the nurse?

Notify the health care provider and prepare to transport the client for a chest x-ray.

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

Which describes the nurse using the technique of percussion?

The nurse notes resonance over the individual's thorax.

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

Up and back

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

Wearing gloves when palpating the tongue, lips, & gums

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

Balance

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 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

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

Finger pads

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

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

Low-frequency sounds

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?

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

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

A nursing student will soon be graduating and beginning a new job at a local health clinic. The nursing student is excited about the new career but also anxious about performing physical assessments of actual clients. Which of the following would be the best way for this student to gain confidence in assessment skills?

Practice performing a physical examination on a classmate, friend, or relative.

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 illustrates the nurse using the technique of inspection?

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

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

To determine whether a structure is filled with air or fluid or is a solid structure

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

Wear clean gloves when administering heparin to the client

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

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

bone

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

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?

inflamed areas of skin