Chapter 3 Techniques and Equipment for Physical Assessment

Chapter 3  Techniques and Equipment for Physical Assessment

Complete Chapter Questions And Answers
 

Sample Questions

MULTIPLE CHOICE

1. What is the most important nursing action to reduce transmission of microorganisms during a 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.

ANS: B

Feedback
A
Cleaning the bell and diaphragm of the stethoscope between patients is important to prevent the spread of microorganisms when auscultating only.
B
Consensus recommendations of the World Health Organization include use of hand hygiene techniques to prevent spread of microorganisms before palpating, percussing, or auscultating patients, and during patient care.
C
Wearing gloves when anticipating exposure to body fluids is important to prevent the spread of microorganisms from the patient while giving care.
D
Wearing eye protection when anticipating spatter of body fluids is important to prevent the spread of microorganisms from the patient while giving care.

DIF: Cognitive Level: Remember REF: 21
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Safety and Infection Control: Standard Precautions/Transmission-Based Precautions/Surgical Asepsis

2. 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.

ANS: B

Feedback
A
Wearing gloves throughout the examination of the patient is unnecessary. Referring to the Standard Precautions for the correct answer; nurses use judgment to determine when contact with body fluids is possible.
B
Specifically, this applies to contact with blood, body fluids (e.g., urine, feces, sputum, wound drainage), nonintact skin, and mucous membranes.
C
Hands must be washed after removal of gloves.
D
The nurse should wear a mask with eye protection or a face shield during procedures that may result in splashes or sprays of the patient’s blood, body fluids, secretions, or excretions.

DIF: Cognitive Level: Understand REF: 22
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Safety and Infection Control: Standard/Transmission-Based/Other Precautions

3. 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.

ANS: C

Feedback
A
Nonlatex gloves may be used only for activities that are not likely to involve contact with infectious materials.
B
NIOSH recommends not using oil-based hand lotions when wearing latex gloves.
C
Use of these types of gloves is recommended by The National Institute for Occupational Safety and Health (NIOSH).
D
NIOSH recommends washing hands after removing latex gloves, not before applying them.

DIF: Cognitive Level: Remember REF: 22, Box 3-2
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Safe and Effective Care Environment: Safety and Infection Control: Standard Precautions/Transmission-Based Precautions/Surgical Asepsis

4. 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?”

ANS: B

Feedback
A
I need to feel for tumors in your neck” uses the term “tumors” and may alarm the patient unnecessarily.
B
Palpating the neck enters the patient’s personal space and may have cultural significance. Thus it is important to inform patients of the impending action and its purpose.
C
“I need to press deeply on your neck so please hold still” may alarm the patient and is not accurate. To palpate the neck, light palpation is used to detect abnormalities such as enlarged nodes. Deep palpation is used on the abdomen.
D
“Is there any tenderness in your neck?” obtains subjective data, but does not tell the patient what the nurse is planning to do.

DIF: Cognitive Level: Apply REF: 23
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

5. 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.

ANS: C

Feedback
A
The bimanual technique is used to entrap an organ or mass (such as the uterus or a growth) between the fingertips to determine size and location and is not palpation.
B
Temperature differences are best detected using the dorsal surface of the hand; this technique is not palpation.
C
Nurse C places the ulnar surface of the hands on the patient’s thorax to detect vibrations. This is considered a light palpation.
D
Light pulsation is performed by pressing in to a depth of approximately 1 cm, rather than 4 cm.

DIF: Cognitive Level: Understand REF: 23
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment