The nurse is preparing to assess the sinuses of an adult client using direct
percussion. Which technique is the most appropriate for this assessment?
1.
... [Show More] Using the hyperextended middle finger of the nondominant hand.
2. Using the closed fist of dominant hand.
3. Using the palm of the nondominant hand.
4. Using the fingertips of the dominant hand.
Correct Answer: 4
Direct percussion is the technique of tapping the body with the fingertips of the
dominant hand. It is used to assess thorax of an infant and also to assess the sinuses
of an adult client.
During auscultation of the breath sounds of an adult male client, the nurse hears
crackling sounds over most of the chest. Which action by the nurse is the most
appropriate?
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.
Correct Answer: 2
Friction on either the bell or the diaphragm from coarse body hair may cause a
crackling sound easily confused with abnormal breath sounds. To avoid artifact
caused from friction, the nurse should wet the hair on the client's chest before
auscultation.
The nurse educator is observing a student nurse who is performing cervical
palpation on an adult client. Which technique is appropriate for this assessment?
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).
Correct Answer: 2
Side-to-side palpation of ½-1 cm in depth will not be sufficient to examine
structures that lie deep within a body cavity or those that are covered with thickmuscle. This may be sufficient to determine the size and consistency of a finding in
the soft tissue (such as a cervical lymph node).
The nurse is preparing to assess a client's abdomen. Place the sequence for an
abdominal assessment is the correct order.
Standard Text: Click on the down arrow for each response in the right column and
select the correct choice from the list.
Response 1. Percussion.
Response 2. Palpation.
Response 3. Auscultation.
Response 4. Inspection.
Correct Answer: 4, 3, 1, 2
The nurse is inspecting a client's chest and upper extremities. Which 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 then examine the arms at the conclusion of the exam, as
the client is re-dressing.
Correct Answer: 3
Inspection begins with a survey of the client's appearance and a comparison of the
right and left sides of the body, which should be nearly symmetrical. The nurse
should compare the left and right arms before moving to the chest.
A client has a reddened area on the left forearm. Which assessment technique
should the nurse use to assess this area?
1. Percussion.
2. Light palpation.
3. Moderate palpation.
4. Deep palpation.
Correct Answer: 2
Light palpation is used to assess surface characteristics, such as skin texture, pulse,
or a tender, inflamed area near the surface of the skin.
While auscultating a client's lungs, the nurse identifies more than one sound.
Which action by the nurse is the most appropriate?
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.
Correct Answer: 4
Closing the eyes and concentrating on each sound may help the nurse focus on the
sound.
The nurse is assessing a client's right lower extremity and notes an area of redness.
Which part of the hand will the nurse use to further assess the client's skin?
1. Fingertips.
2. Metacarpophalgeal joints.
3. Dorsal surface.
4. Ulnar surface.
Correct Answer: 3
The skin on the dorsal surface of the fingers and the hand is thinner; therefore, it is
the best area to assess skin temperature.
The nurse is preparing to percuss the lower lobes of a client's lungs. Which
percussion technique is the most appropriate for the nurse to use during this
assessment?
1. Direct percussion.
2. Blunt percussion.
3. Indirect percussion.
4. Any of the percussion techniques.
Correct Answer: 3
Percussion of the lungs is done using indirect percussion, as it produces sounds
that are clearer and more easily interpreted. Of all the percussion techniques,
indirect is the most commonly used.
The nurse is teaching a group of unlicensed assistive personnel about the
stethoscope. Which statements about the stethoscope are appropriate for the nurse
to include in the teaching session?
Select all that apply.
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 spreadof infection.
5. The binaurals should fit snugly in the ears.
Correct Answer: 1, 2, 5 [Show Less]