Prep U: Chapter 6

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.

-Face shield -Gown -Gloves

For which of the following clients should the nurse choose to perform a focused examination?

A man who has presented with an acute onset of chest pain

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

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

Blood-borne pathogens

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

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 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

The nurse would use what part of the hand when assessing temperature during palpation?

Dorsal surface

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

Eliminate distracting noise from the environment

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

A nurse is preparing to examine a 45-year-old female client with a family history of breast cancer. The nurse explains that she will be performing a routine clinical breast examination of the client today. The client objects to having her breasts examined. How should the nurse respond?

Explain the importance of the examination and the risks of breast cancer

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

Finger pads

The nurse is using a Wood's light for a client who has complaints of itching, burning, and peeling of the skin between his toes. The nurse is assessing for what etiology of the client's symptoms?

Fungal infection

What included in personal protective equipment? Select all that apply

Gloves Gown Mouth, nose, eye protection

When caring for clients in any health care environment, what is the most important technique for preventing infection?

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

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?

Heart sounds

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

Inspection, palpation, percussion, auscultation

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

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

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.

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

Resonance

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

It would be most appropriate for a nurse to use a centimeter-scale ruler for which measurement?

Skin lesion size

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

The nurse is preparing to assess a client's peripheral pulses. The nurse would place the client in which position?

Supine

While beginning the assessment of a client's abdomen, the nurse starts in the middle of the abdomen and expects to hear high-frequency sounds. What part of the stethoscope will provide the best sound with firm skin contact?

The diaphragm

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 illustrates the nurse using the technique of inspection?

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

Which illustrates the nurse using the technique of inspection?

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

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

The nurse detects a small mass in the epigastric area. The nurse detects crepitus over the individual's thorax. The nurse detects increased warmth surrounding an abdominal incision.

Which describes the nurse using the technique of auscultation?

The nurse detects gurgling throughout the abdomen.

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

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

inspection.

While performing a physical examination on an adult client, the nurse can detect the density of an underlying structure by using

percussion.

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

peripheral vascular

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 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

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

-Inspection -Palpation -Auscultation

What steps are involved in the client-to-client transmission of pathogens? (Select all that apply.)

-The nurse's contaminated hands come into direct contact with another client -Organisms are present in the client's immediate environment -Organisms are transferred from the client to the nurse's hands

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

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.

While examining a client, the nurse plans to palpate temperature of the skin by using the

dorsal surface of the hand

The new grad asks the preceptor to explain why the order of the examination is different for the abdomen. The best response by the preceptor would include

"Palpation will increase bowel motility and alter the sounds heard on auscultation."

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."