Deck 6: Techniques Equipment

Question 1

The nurse is preparing to assess the thorax of an infant using the assessment technique of direct percussion.To correctly perform this assessment the nurse will use the:
1)hyperextended middle finger of the nondominant hand.
2)closed fist of dominant hand.
3)palm of the nondominant hand.
4)fingertips of the dominant hand.

Answer 1

4

Question 2

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 of the following colors is visualized through the red-free filter of the ophthalmoscope?
1)Green
2)Black
3)Red
4)Yellow

Answer 2

2

Question 3

While auscultating a client's lungs,the nurse identifies more than one sound.Which of the following should the nurse do?
1)Obtain a stethoscope with longer tubing.
2)Ask another nurse to listen to the lung sounds.
3)Hold the stethoscope tubing while listening to the lung sounds.
4)Close the eyes and focus on one sound at a time.

Answer 3

4

Question 4

The nurse is assessing a client for hepatomegaly by percussing over the liver.The nurse would expect to hear which of the following sounds when percussing the liver?
1)Loud,low-pitched
2)Soft,high-pitched
3)Drum-like
4)Abnormally loud

Question 5

A client is brought to the emergency department by ambulance after being found on the floor by a family member.The nurse begins the assessment of the client.Which of the following findings would indicate,to the nurse,the need for a more detailed neurological assessment of this client?
1)Asymmetry of the client's smile
2)Grimacing with movement
3)Talking in a loud voice
4)Inability to follow directions

Question 6

During auscultation of the breath sounds of an adult male client,the nurse hears crackling sounds over most of the chest.Which of the following would be the best action for the nurse to take next?
1)Document this as abnormal.
2)Wet the chest hair before auscultating the chest.
3)Place the diaphragm on top of the client's shirt.
4)Switch from the diaphragm to the bell.

Question 7

The nurse is assessing an anxious-appearing client who is experiencing abdominal pain.The nurse should use which of the following techniques to put the client at ease when assessing the client's abdomen?
1)Palpate known painful areas first.
2)Touch each area lightly before applying deeper palpation.
3)Perform the exam as quickly as possible.
4)Refrain from conversation during the assessment.

Question 8

The nurse is preparing to assess a client's abdomen.Which of the following sequences will the nurse use to assess this body area?
1)Percussion,Palpation,Auscultation,Inspection
2)Auscultation,Inspection,Palpation,Percussion
3)Inspection,Palpation,Percussion,Auscultation
4)Inspection,Auscultation,Percussion,Palpation

Question 9

The nurse is preparing to perform a complete health assessment on a client.Which of the following activities should the nurse perform just prior to this examination?
1)Put on nonsterile gloves.
2)Provide an opportunity for the client to void.
3)Wash hands in the presence of the client.
4)Turn on soft music to relax the client.
5)Lower the lights in the room to prevent glare.

Question 10

The nurse is preparing to percuss the lower lobes of a client's lungs.The percussion technique appropriate for this body area would be:
1)direct percussion.
2)blunt percussion.
3)indirect percussion.
4)any of the percussion techniques.

Question 11

The nurse is assessing a client's right lower extremity and during inspection notes an area of redness.In order to assess the temperature of the client's skin,the nurse should use which part of the hand?
1)Fingertips
2)Metacarpophalgeal joints
3)Dorsal surface
4)Ulnar surface

Question 12

A client has a reddened area on the left forearm.Which of the following assessment techniques should the nurse use to assess this area?
1)Percussion
2)Light palpation
3)Moderate palpation
4)Deep palpation

Question 13

The nursing instructor is observing a student nurse who is performing abdominal palpation on an adult client.In order to assess organs that lie deep within the abdominal cavity (e.g. ,kidneys,spleen),the student nurse should press on the client's abdomen using which of the following techniques?
1)Downward pressure of 1-2 cm using the finger pads
2)Side to side pressure of ½-1 cm using the finger pads
3)Downward pressure of 2-4 cm using the palmar surface of the fingers
4)Light pressure using the base of the fingers (metacarpophalangeal joints)

Question 14

The nursing instructor is demonstrating,to a group of nursing students,the proper technique for assessing a client for fremitus.Which part of the hand will the instructor use to demonstrate proper technique?

Question 15

The nurse uses the otoscope in the physical assessment of a client.The nurse understands that this instrument is used to:
1)Inspect the nose.
2)Funnel light into the ear canal.
3)Inspect the internal structures of the eye.
4)Assess pulses that are not palpable.
5)Detect fungal infections of the skin.

Question 16

The nurse is assessing an adult client when suddenly the client refuses to continue the examination.What is the nurse's next step?
1)Give the client a short break and then resume the assessment.
2)Document what was done and what was refused.
3)Summon another nurse to the room to serve as a witness.
4)Enlist the assistance of the client's family to encourage the rest of the assessment.

Question 17

The nurse is teaching a group of health assistants about the stethoscope.Which of the following statements about the stethoscope will the nurse include in this teaching session?
1)The stethoscope works by blocking out environmental sounds.
2)Short tubing provides the listener with the most accurate sounds.
3)The bell of the stethoscope is used for high-pitched sounds,such as lung sounds.
4)Cleaning the stethoscope is not necessary since it is not a vehicle for the spread of infection.
5)The binaurals should fit snugly in the ears.

Question 18

The nurse is inspecting a client's chest and upper extremities.Which of the following would be the appropriate method for the nurse to assess these body areas?
1)Examine the right arm,the chest,and then the left arm.
2)Examine the left arm,the chest,and then the right arm.
3)Examine the left arm,the right arm,and then the chest.
4)Examine the chest and examine the arms at the conclusion of the exam as the client is re-dressing.

Question 19

The nursing instructor is teaching a group of nursing students the correct assessment of normal heart sounds.Draw an arrow on the part of the stethoscope that should be used by the nursing student to auscultate normal heart sounds.

Question 20

The nurse is about to perform a physical assessment on an adult client.Before beginning this phase of the client's health assessment,the nurse should first:
1)Provide a gown for the client to change into.
2)Explain to the client what will happen during the examination.
3)Obtain a written consent.
4)Wash hands in the presence of the client.

Question 21

The nurse is preparing to examine several clients in the clinic setting.Which of the following clients would need the greatest degree of special consideration during a physical examination?
1)59-year old with flu symptoms
2)3-year-old child in for a well check-up
3)17-year old who complains of fatigue
4)68-year old with chronic lung disease

Question 22

A senior nursing student is working in an elementary school with the school nurse.The student cares for a child who fell on the school playground and sustained multiple abrasions to the lower extremities.Which action by the nursing student would require immediate intervention by the school nurse?
1)The student nurse puts on nonsterile gloves prior to assessing the child's injuries.
2)The student nurse disposes of blood-soaked gauze in the office trash bin.
3)The student nurse performs handwashing before touching the child.
4)The student nurse asks the child permission to assess the injuries.

Question 23

The nurse is preparing to assess an adult client who presents to the emergency room 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 of the following should the nurse incorporate into the physical assessment of this client?
1)Wash hands in the presence of the client.
2)Put on nonsterile gloves to examine the client.
3)Ensure that the client has an empty bladder before beginning the physical assessment.
4)Instruct the client to hold all questions and comments until the completion of the assessment so that the nurse can focus on the exam.
5)Assess only the left lower extremity since this is the injured body part.

Question 24

The nurse is unable to palpate a client's pedal pulses.Which of the following items will the nurse use to help locate this client's pedal pulses?
1)Stethoscope
2)Doppler
3)Transilluminator
4)Goniometer

Question 25

The nurse is performing an abdominal assessment and has just completed inspection.Which of the following techniques would the nurse correctly choose to use next in this assessment?
1)Percussion
2)Palpation
3)Transillumination
4)Auscultation

Question 26

While performing a physical assessment on an adult client,the nurse identifies an unfamiliar heart sound.The nurse suspects that this is a murmur.What is the nurse's next step?
1)Inform the client of "the abnormality."
2)Stop the assessment and refer the client to the healthcare provider immediately.
3)Bring in another examiner to assess the finding.
4)Document the finding and reassess at the client's next visit.

Question 27

While percussing a client's lung area the nurse notes a flat tone.This tone would indicate:
1)The nurse is percussing over a bone.
2)A normal finding.
3)The lungs are solidified.
4)Air is trapped in the lungs.

Question 28

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.What is the nurse's next action?
1)Check the pressure applied to the probe.
2)Add more gel to the end of the probe.
3)Immediately inform the healthcare provider.
4)Send the equipment for repair.

Question 29

The nurse is conducting an assessment of a client with right lower quadrant abdominal pain.Which of the following should the nurse do when palpating the abdomen of this client?
1)Assess the painful area first using moderate palpation.
2)Assess the painful area last using deep palpation.
3)Assess the painful area last using light palpation.
4)Assess the painful area first using deep palpation.