PrepU - ch. 3: collecting objective data: the physical examination

What included in personal protective equipment? Select all that apply.

- gloves - gown - mouth, nose, eye protection

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

- inspection - palpation - auscultation

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

- wash hands - obtain and check needed equipment - identify ways to ensure client privacy

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 student nurse is palpating the neck of a client who reports a lump behind the ear. While palpating, the student nurse notes that the lump is immobile. Which action by the student nurse is best in response to this finding?

Consult with a clinical instructor

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

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

Dorsal surface

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

Which illustrates the nurse using the technique of inspection?

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

Sometimes it is necessary to use a tuning fork when performing a physical assessment. What would be one instance where a tuning fork would be used?

To determine vibration sense in the neuromuscular system

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 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

The nurse understands that the preferred method of hand hygiene when hands are not visibly soiled is what?

alcohol based rub

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

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

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

finger pads

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

hearing loss

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

light palpation

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

palpation

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

resonance

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

strength of a reflex

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

While performing a physical examination on an older adult, the nurse should plan to...

use minimal position changes

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."

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

Blood-borne pathogens

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

Dorsal surface

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

A nurse is beginning the physical examination of an elderly man with chronic obstructive pulmonary disease. In which order should the nurse implement the four physical assessment techniques with this client?

Inspection, palpation, percussion, auscultation

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

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

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

Wearing gloves when palpating the tongue, lips, & gums

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

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

dorsal surface of the hand.

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

examining the tongue

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

Light palpation is most appropriate to assess the...

inflamed areas of skin

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

inspection

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

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

Your lab instructor explains that physical examination relies on what cardinal assessment technique?

percussion

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 assess a client's abdomen. Which client position would be best for this assessment?

supine

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

up and back