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6001 NURSING-Actual
solutions
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, non-intact skin, or wound dressings. The nurse's hands do not appear to be visibly soiled. What hand hygiene should the nurse perform? - ANS-application of an antiseptic handrub Which action by a nurse demonstrates the correct application of the principles of standard precautions? - ANS-wearing gloves when palpating the tongue, lips, and gums
The nurse is preparing to auscultate sounds that have a lower pitch. Which equipment should be used to complete this assessment? - ANS-stethoscope bell The nurse selects a tuning fork to use when assessing a client. Which body system is the nurse most likely assessing? - ANS- peripheral vascular A client is experiencing weakness of the left side of the body. Which piece of equipment should the nurse use to determine if the client's neurologic system is intact? - ANS-reflex hammer A nurse on an oncology unit enters a client's room to auscultate bowel sounds. What should the nurse do before auscultating? - ANS-Disinfect the stethoscope before touching the client What guidelines should the nurse keep in mind while performing auscultation? - ANS-Eliminate distracting noise from the environment A nurse is admitting a new client to the subacute medical unit and is completing a comprehensive assessment. The nurse is appropriately applying standard precautions by performing what action? - ANS-wear gloves to palpate the tongue and buccal membranes During a comprehensive assessment, the primary technique used by the nurse throughout the examination is - ANS-inspection Light palpation is most appropriate to assess the - ANS-inflamed areas of the skin
A nurse needs to obtain a pulse on a client. Which physical assessment technique should the nurse use? - ANS-light palpation The nurse is completing a physical examination of a client who reports ear pain. In order to determine if the tympanic membrane is still intact, which instrument is required? - ANS-otoscope When performing a physical assessment on an older adult client, what should the nurse consider offering this client? - ANS-an extra blanket A nurse is preparing to perform intubation on a client. Which pieces of equipment are needed to prevent the transmission of infectious agents during this procedure? - ANS-gloves, face shield, gown What is included in PPE - ANS-gloves, gowns, masks, protective eyewear Which of the following would be most important for the nurse to do immediately before beginning the physical exam? - ANS- collect necessary equipment essential to the exam 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? - ANS-Snellen Chart A nurse will be performing a complete physical examination of a man who has emphysema with a chronic productive cough, including an assessment of his oral cavity. Which pieces of
personal protective equipment should the nurse wear? - ANS- gloves, mask, protective eye goggles, gown A nurse has gathered the necessary equipment for the physical assessment of an adult client. It would be most appropriate for a nurse to use a centimeter-scale ruler for which measurement? - ANS-skin lesion size A nurse often has the option to use an alcohol-based hand rub for hand hygiene, but proper technique is essential in its use. What is the proper technique for the use of an alcohol-based hand rub? - ANS-rub the hands and fingers until dry A nurse is preparing to evaluate an elderly 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? - ANS-Braden scale A nurse is preparing to perform a genital examination of a female client. Which of the following positions should the nurse place the client in? - ANS-lithotomy In which order should a nurse implement the four physical assessment techniques when initiating a health assessment? - ANS-inspection, palpation, percussion, auscultation the nurse is conducting a physical examination of the abdomen. What is the nurse's best action to ensure she can hear bowel sounds? - ANS-reduce all environmental noise A client with scabies visits the health care facility for a follow-up appointment. Which preparation by the nurse is of greatest priority
