Deck 9: Techniques and Equipment

Question 1

The nurse educator is demonstrating the proper technique for assessing a client for fremitus. Which part of the hand will the instructor use to demonstrate proper technique?

A) A.
B) B.
C) C.
D) D.

Answer 1

C.

Question 2

The nurse is assessing an anxious-appearing client who is experiencing abdominal pain. Which technique is appropriate for the nurse to use when assessing this client's abdomen?

A) Palpating known painful areas first.
B) Touching each area lightly before applying deeper palpation.
C) Performing the exam as quickly as possible.
D) Refraining from conversation during the assessment.

Answer 2

Touching each area lightly before applying deeper palpation.

Question 3

A client is brought to the emergency department (ED) by ambulance after being found on the floor by a family member. The nurse begins the assessment of the client. Which finding would indicate the need for a more detailed neurological assessment of this client?

A) Asymmetry of the client's smile.
B) Grimacing with movement.
C) Talking in a loud voice.
D) Inability to follow directions.

Answer 3

Asymmetry of the client's smile.

Question 4

The nurse is assessing a client's abdomen. Which sound is expected when percussion is used during the assessment?

A) Loud, low-pitched.
B) Soft, high-pitched.
C) Drum-like.
D) Abnormally loud.

Question 5

The nurse is planning to perform a physical assessment on an adult client. Before beginning this phase of the client's health assessment, which action by the nurse is the most appropriate?

A) Provide a gown for the client to change into.
B) Explain to the client what will happen during the examination.
C) Obtain a written consent.
D) Wash hands in the presence of the client.

Question 6

The nurse is inspecting a client's chest and upper extremities. Which would be the appropriate method for the nurse to assess these body areas?

A) Examine the right arm, the chest, and then the left arm.
B) Examine the left arm, the chest, and then the right arm.
C) Examine the left arm, the right arm, and then the chest.
D) Examine the chest, and then examine the arms at the conclusion of the exam, as the client is re-dressing.

Question 7

The nurse is using an ophthalmoscope to assess the optic disc in a client. The nurse would suspect hemorrhage of the optic disc is present when which color is visualized through the red-free filter of the ophthalmoscope?

A) Green.
B) Black.
C) Red.
D) Yellow.

Question 8

The nurse is assessing an adult client when suddenly the client refuses to continue the examination. Which action by the nurse is the priority?

A) Give the client a short break and then resume the assessment.
B) Document what was done and what was refused.
C) Summon another nurse to the room to serve as a witness.
D) Enlist the assistance of the client's family to encourage the rest of the assessment.

Question 9

The nurse is assessing a client's right lower extremity and notes an area of redness. Which part of the hand will the nurse use to further assess the client's skin?

A) Fingertips.
B) Metacarpophalgeal joints.
C) Dorsal surface.
D) Ulnar surface.

Question 10

The nurse is preparing to percuss the lower lobes of a client's lungs. Which percussion technique is the most appropriate for the nurse to use during this assessment?

A) Direct percussion.
B) Blunt percussion.
C) Indirect percussion.
D) Any of the percussion techniques.

Question 11

The nurse is teaching a group of unlicensed assistive personnel about the stethoscope. Which statements about the stethoscope are appropriate for the nurse to include in the teaching session?

A) The stethoscope works by blocking out environmental sounds.
B) Short tubing provides the listener with the most accurate sounds.
C) The bell of the stethoscope is used for high-pitched sounds, such as lung sounds.
D) Cleaning the stethoscope is not necessary since it is not a vehicle for the spread of infection.
E) The binaurals should fit snugly in the ears.

Question 12

During auscultation of the breath sounds of an adult male client, the nurse hears crackling sounds over most of the chest. Which action by the nurse is the most appropriate?

A) Document this as abnormal.
B) Wet the chest hair before auscultating the chest.
C) Place the diaphragm on top of the client's shirt.
D) Switch from the diaphragm to the bell.

Question 13

The nurse is performing an abdominal assessment and has just completed auscultation. Which technique would the nurse correctly choose to use next in this assessment?

A) Percussion.
B) Palpation.
C) Transillumination.
D) Auscultation.

Question 14

The nurse is preparing to assess the sinuses of an adult client using direct percussion. Which technique is the most appropriate for this assessment?

A) Using the hyperextended middle finger of the nondominant hand.
B) Using the closed fist of dominant hand.
C) Using the palm of the nondominant hand.
D) Using the fingertips of the dominant hand.

Question 15

The nurse is preparing to assess a client's abdomen. Place the sequence for an abdominal assessment is the correct order. Standard Text: Click on the down arrow for each response in the right column and select the correct choice from the list.
Response

A) Percussion. Response
B) Palpation. Response
C) Auscultation. Response
D) Inspection.

Question 16

A client has a reddened area on the left forearm. Which assessment technique should the nurse use to assess this area?

A) Percussion.
B) Light palpation.
C) Moderate palpation.
D) Deep palpation.

Question 17

The nurse educator is observing a student nurse who is performing cervical palpation on an adult client. Which technique is appropriate for this assessment?

A) Downward pressure of 1-2 cm using the finger pads.
B) Side to side pressure of ½-1 cm using the finger pads.
C) Downward pressure of 2-4 cm using the palmar surface of the fingers
D) Light pressure using the base of the fingers (metacarpophalangeal joints).

Question 18

The nurse is preparing to perform a complete health assessment on a client. Which actions by the nurse are appropriate just prior to the examination?

A) Putting on nonsterile gloves.
B) Providing an opportunity for the client to void.
C) Washing hands in the presence of the client.
D) Turning on soft music to relax the client.
E) Ensuring adequate light in the room.

Question 19

When is it appropriate for the nurse to use an otoscope during a physical assessment?

A) Inspecting the nose.
B) Funneling light into the ear canal.
C) Inspecting the internal structures of the eye.
D) Assessing pulses that are not palpable.
E) Detecting fungal infections of the skin.

Question 20

While auscultating a client's lungs, the nurse identifies more than one sound. Which action by the nurse is the most appropriate?

A) Obtain a stethoscope with longer tubing.
B) Ask another nurse to listen to the lung sounds.
C) Hold the stethoscope tubing while listening to the lung sounds.
D) Close the eyes and focus on one sound at a time.

Question 21

While performing a physical assessment on an adult client, the nurse identifies an unfamiliar heart sound. The nurse suspects that this is a murmur. Which nursing action is most appropriate?

A) Informing the client of "the abnormality."
B) Stopping the assessment and referring the client to the healthcare provider immediately.
C) Bring in another examiner to assess the finding.
D) Documenting the finding and reassessing at the client's next visit.

Question 22

The nurse is preparing to examine several clients in the clinic setting. Which client would need the greatest degree of special consideration during a physical examination?

A) An adult client with flu symptoms.
B) A preschool-age client in for a well check-up.
C) An adolescent client who complains of fatigue.
D) An older adult client with chronic lung disease.

Question 23

A client has a visible pulsation in the middle of his abdomen. Which assessment technique is appropriate for the nurse to use to assess this pulsation?

A) Percussion.
B) Light palpation.
C) Moderate palpation.
D) Deep palpation.

Question 24

The school nurse provides care for a child who fell on the school playground and sustained multiple abrasions to the lower extremities. Which actions by the school nurse are appropriate when caring for this child?

A) Putting on nonsterile gloves prior to assessing the child's injuries.
B) Disposing of blood-soaked gauze in the office trash bin.
C) Performing handwashing before touching the child.
D) Asking the child permission to assess the injuries.
E) Wearing a mask while washing the child's abrasions.

Question 25

The nurse is unable to palpate a client's pedal pulses. Which item will the nurse use to assess this client's pedal pulses?

A) Stethoscope.
B) Doppler.
C) Transilluminator.
D) Goniometer.

Question 26

The nurse is conducting an assessment of a client with right lower quadrant abdominal pain. Which action by the nurse is appropriate when palpating this client's abdomen?

A) Assessing the painful area first using moderate palpation.
B) Assessing the painful area last using deep palpation.
C) Assessing the painful area last using light palpation.
D) Assessing the painful area first using deep palpation.

Question 27

The nurse is using a Doppler ultrasonic stethoscope to assess a client's pulse in the lower extremity and is unable to locate the pulse. Which action by the nurse is appropriate in this situation?

A) Checking the pressure applied to the probe.
B) Adding more gel to the end of the probe.
C) Informing the healthcare provider immediately.
D) Sending the equipment for repair.

Question 28

While percussing a client's lung area the nurse notes a resonance. What does the tone indicate?

A) The nurse is percussing over a bone.
B) A normal finding.
C) The lungs are solidified.
D) Air is trapped in the lungs.

Question 29

The nurse is preparing to assess an adult client who presents to the emergency department (ED) after falling down some steps at home. The client complains of left ankle pain and has open abrasions to the left knee and shin. Which should the nurse incorporate into the physical assessment of this client?

A) Washing hands in the presence of the client.
B) Putting on nonsterile gloves to examine the client.
C) Ensuring that the client has an empty bladder before beginning the physical assessment.
D) Instructing the client to hold all questions and comments until the completion of the assessment so that the nurse can focus on the exam.
E) Assessing only the left lower extremity since this is the injured body part.