Techniques And Equipment For Physical Assessment

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Question 1

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Multiple Choice

What is the most important nursing action to reduce transmission of microorganisms prior to initiation of the physical assessment?

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Clean the bell and diaphragm of the stethoscope between patients.

Perform hand hygiene.

Wear gloves when anticipating exposure to body fluids.

Wear eye protection when anticipating spatter of body fluids.

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Question 2

Free

Multiple Choice

When examining a patient, the nurse remembers to follow which principle of Standard Precautions?

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Wear gloves throughout the entire examination of the patient.

Wear gloves when in contact with the patient's mucous membranes.

Wear gloves to reduce the need for handwashing.

Wear eye protection and a gown during the examination of the patient.

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Question 3

Free

Multiple Choice

How do nurses prevent a latex allergy?

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They use nonlatex gloves for all procedures.

They protect their hands using oil-based hand lotion applying latex gloves.

They use a powder-free, low-allergen latex gloves.

They wash their hands with mild soap and dry thoroughly before applying latex gloves.

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Question 4

Free

Multiple Choice

Which explanation is most appropriate for a nurse preparing to palpate a patient's neck?

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"I need to feel for tumors in your neck."

"I'm going to feel your neck for any abnormalities."

"I need to press deeply on your neck so please hold still."

"Is there any tenderness in your neck?"

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Question 5

Free

Multiple Choice

Which nurse is performing the technique of light palpation appropriately?

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Nurse A applies the bimanual technique to determine size and location of the patient's heart.

Nurse B uses the fingertips to feel for temperature differences on the patient's legs.

Nurse C places the ulnar surface of the hands on the patient's thorax to detect vibrations.

Nurse D depresses the patient's abdomen approximately 4 cm to assess pulsations.

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Question 6

Multiple Choice

How does the nurse perform the bimanual technique of palpation to assess organs?

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Using the palmar surface of the dominant hand to press inward to a depth of about 1 cm

Holding a light source in one hand while stroking the skin lightly with the dominant hand

Using the ulnar surfaces of both hands to press inward 4 to 5 cm

Using both hands, one anterior and one posterior, to entrap an organ between the fingertips

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Question 7

Multiple Choice

While assessing a patient's lower extremities, the nurse suspects the lower extremities feel cooler than the upper extremities. To confirm this suspicion, how does the nurse compare the temperatures of the lower extremities with the upper extremities?

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Using the backs (dorsum) of the hands to detect differences

Using the ulnar surface of the hands to detect differences

Using the pads of the fingers to detect differences

Using the palmar surface (underside) of the hands to detect differences

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Question 8

Multiple Choice

How does a nurse assess for fluid in a patient's abdomen?

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Placing the nondominant hand (pleximeter) over the area to be percussed, and striking the index finger of the pleximeter with the pad of the middle finger of the dominant hand

Applying indirect percussion by tapping one finger lightly on the abdominal wall with the plexor

Placing the middle finger of the nondominant hand (pleximeter) over the area to be percussed, and striking that finger with the tip of the middle finger of the dominant hand

Using direct percussion by placing one hand over the abdomen and striking lightly with the other hand

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Question 9

Multiple Choice

What assessment data do nurses obtain through striking a hand directly against the flank or costovertebral angle of a patient's body?

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Fluid in the lungs

Tenderness over the kidneys

Air in the abdomen

Tenderness over the liver

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Question 10

Multiple Choice

A patient has been complaining of abdominal cramping and gas; the nurse notes that his abdomen is slightly distended. Which sound does the nurse expect to hear during percussion of this patient's abdomen?

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Flatness

Dullness

Resonance

Tympany

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Question 11

Multiple Choice

The nurse is unable to hear the patient's breath sounds. What checks does the nurse make of the stethoscope to determine the cause of this problem?

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Ensure the stethoscope tubing is at least 20 inches long.

Ensure the valve is open to the diaphragm on the head of the stethoscope.

Ensure the earpieces are pointed toward the back of the ears.

Ensure the bell is placed firmly against the patient's skin.

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Question 12

Multiple Choice

What part of the stethoscope do nurses use to auscultate the chest?

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Press the bell firmly against the skin to hear sounds and vibrations.

The bell of the stethoscope is used to hear breath sounds.

The diaphragm of the stethoscope is used to hear heart sounds.

Either the bell or the diaphragm is used to auscultate the chest.

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Question 13

Multiple Choice

How does the nurse detect an extra heart sound in an adult?

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Using the bell of a stethoscope

With a pulse oximeter

Using the diaphragm of a stethoscope

With a Doppler ultrasound probe

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Question 14

Multiple Choice

A nurse is preparing to take a patient's blood pressure. The blood pressure cuff is 5 inches wide and the patient's upper arm circumference is 20 inches. How accurate will this patient's blood pressure be using this blood pressure cuff?

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Accurate, the actual value

Higher than the actual value

Lower than the actual value

Unable to determine accuracy with available data

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Question 15

Multiple Choice

Where does the nurse attach the sensor probe of the pulse oximeter to measure an adult patient's oxygen saturation?

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The chest over the patient's heart

Over the patient's abdominal aorta

Over the patient's radial pulse

Around the patient's index finger nail

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Question 16

Multiple Choice

The patient asks about the meaning of his visual assessment of 20/40 using a Snellen visual acuity chart. What is the nurse's appropriate response?

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"20/40 means your vision is about two times normal."

"A person with corrected vision can see at 20 feet what you can see at 40 feet."

"A person with normal vision can see at 20 feet what you can see at 40 feet."

"A person with normal vision can see at 40 feet what you can see at 20 feet."

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Question 17

Multiple Choice

The nurse is using the Snellen chart to assess a patient's vision. The patient states that the green line on the chart is shorter than the red line. What is the interpretation of this finding?

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This patient has normal color perception and abnormal field perception.

This patient is color blind but has normal field perception.

This patient's color perception and field perception are normal.

This patient is color blind and has abnormal field perception.

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Question 18

Multiple Choice

What tool does the nurse use to assess the patient's near vision?

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A Snellen eye chart placed about 12 inches from the patient's face

An ophthalmoscope with the diopter set at 0 (zero)

A Jaeger or Rosenbaum chart placed about 2 feet from the patient's face

A newspaper held about 14 inches from the patient's face

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Question 19

Multiple Choice

Using an ophthalmoscope, how does the nurse bring a patient's interior eye structures into focus?

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Using the red filter

Adjusting the diopters

Dilating the patient's pupils

Using the wide-beam light

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Question 20

Multiple Choice

Which action by the nurse describes the correct technique for using an otoscope on an adult?

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Using the pneumatic attachment to observe for tympanic fluctuation

Striking the otoscope against the hand to engage

Instructing the adult to raise one finger when a sound is heard

Selecting the largest size speculum that fits into the adult's ear canal

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