Deck 3: Techniques and Equipment for Physical Assessment

Question 1

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

A) Wear gloves throughout the entire examination of the patient.
B) Wear gloves when in contact with the patient's mucous membranes.
C) Wear gloves to reduce the need for handwashing.
D) Wear eye protection and a gown during the examination of the patient.

Answer 1

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

Question 2

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?

A) Accurate, the actual value
B) Higher than the actual value
C) Lower than the actual value
D) Unable to determine accuracy with available data

Answer 2

Higher than the actual value

Question 3

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

A) Clean the bell and diaphragm of the stethoscope between patients.
B) Perform hand hygiene.
C) Wear gloves when anticipating exposure to body fluids.
D) Wear eye protection when anticipating spatter of body fluids.

Answer 3

Perform hand hygiene.

Question 4

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

A) 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
B) Applying indirect percussion by tapping one finger lightly on the abdominal wall with the plexor
C) 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
D) Using direct percussion by placing one hand over the abdomen and striking lightly with the other hand

Question 5

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?

A) Ensure the stethoscope tubing is at least 20 inches long.
B) Ensure the valve is open to the diaphragm on the head of the stethoscope.
C) Ensure the earpieces are pointed toward the back of the ears.
D) Ensure the bell is placed firmly against the patient's skin.

Question 6

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

A) A Snellen eye chart placed about 12 inches from the patient's face
B) An ophthalmoscope with the diopter set at 0 (zero)
C) A Jaeger or Rosenbaum chart placed about 2 feet from the patient's face
D) A newspaper held about 14 inches from the patient's face

Question 7

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

A) Using the red filter
B) Adjusting the diopters
C) Dilating the patient's pupils
D) Using the wide-beam light

Question 8

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?

A) "20/40 means your vision is about two times normal."
B) "A person with corrected vision can see at 20 feet what you can see at 40 feet."
C) "A person with normal vision can see at 20 feet what you can see at 40 feet."
D) "A person with normal vision can see at 40 feet what you can see at 20 feet."

Question 9

How do nurses prevent a latex allergy?

A) They use nonlatex gloves for all procedures.
B) They protect their hands using oil-based hand lotion applying latex gloves.
C) They use a powder-free, low-allergen latex gloves.
D) They wash their hands with mild soap and dry thoroughly before applying latex gloves.

Question 10

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

A) Using the bell of a stethoscope
B) With a pulse oximeter
C) Using the diaphragm of a stethoscope
D) With a Doppler ultrasound probe

Question 11

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

A) Press the bell firmly against the skin to hear sounds and vibrations.
B) The bell of the stethoscope is used to hear breath sounds.
C) The diaphragm of the stethoscope is used to hear heart sounds.
D) Either the bell or the diaphragm is used to auscultate the chest.

Question 12

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

A) "I need to feel for tumors in your neck."
B) "I'm going to feel your neck for any abnormalities."
C) "I need to press deeply on your neck so please hold still."
D) "Is there any tenderness in your neck?"

Question 13

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?

A) Flatness
B) Dullness
C) Resonance
D) Tympany

Question 14

Which nurse is performing the technique of light palpation appropriately?

A) Nurse A applies the bimanual technique to determine size and location of the patient's heart.
B) Nurse B uses the fingertips to feel for temperature differences on the patient's legs.
C) Nurse C places the ulnar surface of the hands on the patient's thorax to detect vibrations.
D) Nurse D depresses the patient's abdomen approximately 4 cm to assess pulsations.

Question 15

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

A) Fluid in the lungs
B) Tenderness over the kidneys
C) Air in the abdomen
D) Tenderness over the liver

Question 16

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?

A) This patient has normal color perception and abnormal field perception.
B) This patient is color blind but has normal field perception.
C) This patient's color perception and field perception are normal.
D) This patient is color blind and has abnormal field perception.

Question 17

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

A) Using the pneumatic attachment to observe for tympanic fluctuation
B) Striking the otoscope against the hand to engage
C) Instructing the adult to raise one finger when a sound is heard
D) Selecting the largest size speculum that fits into the adult's ear canal

Question 18

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

A) Using the palmar surface of the dominant hand to press inward to a depth of about 1 cm
B) Holding a light source in one hand while stroking the skin lightly with the dominant hand
C) Using the ulnar surfaces of both hands to press inward 4 to 5 cm
D) Using both hands, one anterior and one posterior, to entrap an organ between the fingertips

Question 19

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?

A) Using the backs (dorsum) of the hands to detect differences
B) Using the ulnar surface of the hands to detect differences
C) Using the pads of the fingers to detect differences
D) Using the palmar surface (underside) of the hands to detect differences

Question 20

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

A) The chest over the patient's heart
B) Over the patient's abdominal aorta
C) Over the patient's radial pulse
D) Around the patient's index finger nail

Question 21

A nurse is preparing to assess a patient's ability to detect vibrations. Which piece of equipment is appropriate for this assessment?

A) Reflex hammer
B) Tuning fork
C) Goniometer
D) Monofilament

Question 22

To test deep tendon reflexes, the nurse uses which instrument?

A) Goniometer
B) Calipers
C) Reflex hammer
D) Monofilament

Question 23

What are characteristics of an audioscope?

A) Screens for hearing ability
B) Allows visualization into the ear canal
C) Must be calibrated before use
D) Uses vibration to estimate hearing loss

Question 24

When does a nurse choose to use skinfold calipers when collecting assessment data?

A) Calculating the patient's body mass index
B) Inspecting the patient's skin
C) Determining the amount of the patient's lean body tissue
D) Estimating the amount of the patient's body fat

Question 25

A nurse is assessing joint function of a patient with severe rheumatoid arthritis. Which instrument/tool does the nurse use to measure the degree of flexion and extension of the patient's knee joints?

A) Calipers
B) Ruler or tape measure
C) Goniometer
D) Doppler

Question 26

A patient with type 2 diabetes mellitus has an infected lesion on his foot. During the history of his present illness, he reports, "I had a cut on my foot, but I did not even feel it." What equipment does the nurse use to gather more data about his foot?

A) A Wood lamp
B) Transilluminator
C) Monofilament
D) Reflex hammer

Question 27

A patient is complaining of pain over the maxillary sinuses. Which device does the nurse use to determine if there is air or fluid in the patient's sinuses?

A) Magnification device
B) Transilluminator
C) Monofilament
D) Wood lamp

Question 28

A nurse suspects that a large skin lesion on the patient's forearm is a fungal infection. Which device does the nurse use to confirm his suspicion?

A) Pen light
B) Magnification device
C) Transilluminator
D) Wood lamp

Question 29

When does a nurse use a Pederson or Graves speculum for examination of a patient?

A) To inspect the external ear
B) To assess the vaginal canal
C) To inspect nasal passages
D) To assess the oropharynx

Question 30

A nurse is using the finger pads to palpate a patient's dorsalis pedis pulses and is unable to feel any pulses. Which action is appropriate for the nurse to perform next?

A) Document that the dorsalis pedis pulses are not palpable.
B) Have the patient stand and try again to palpate the pulses.
C) Use a Doppler to detect the presence of the pulses.
D) Palpate the dorsalis pedis pulses using the ulnar surface of the hand.

Question 31

How does the nurse detect a pulse when using a Doppler?

A) The pulsation is felt.
B) The pulsation is heard.
C) The pulse wave is seen on a screen.
D) The pulse wave is printed out on special paper.