NRS 2014 FINAL STUDY SET EXAM WITH
COMPLETE SOLUTIONS
The nurse is preparing to assess a patient's abdomen by palpation. How should the
nurse proceed?
Palpation of reportedly "tender" areas are avoided because palpation in these areas
may cause pain.
Palpating a tender area is quickly performed to avoid any discomfort that the patient
may experience.
The assessment begins with deep palpation, while encouraging the patient to relax and
to take deep breaths.
The assessment begins with light palpation to detect surface characteristics and to
accustom the patient to being touched. - ANSWER The assessment begins with light
palpation to detect surface characteristics and to accustom the patient to being
touched.
The nurse would use bimanual palpation technique in which situation?
Palpating the thorax of an infant
Palpating the kidneys and uterus
Assessing pulsations and vibrations
Assessing the presence of tenderness and pain - ANSWER Palpating the kidneys and
uterus
The nurse is reviewing percussion techniques with a newly graduated nurse. Which
technique, if used by the new nurse, indicates that more review is needed?
Percussing once over each area
Quickly lifting the striking finger after each stroke
Striking with the fingertip, not the finger pad
Using the wrist to make the strikes, not the arm - ANSWER Percussing once over each
area
, When percussing over the liver of a patient, the nurse notices a dull sound. The nurse
should:
Consider this a normal finding.
Palpate this area for an underlying mass.
Reposition the hands, and attempt to percuss in this area again.
Consider this finding as abnormal, and refer the patient for additional treatment... -
ANSWER Consider this a normal finding.
The nurse is unable to identify any changes in sound when percussing over the
abdomen of an obese patient. What should the nurse do next?
Ask the patient to take deep breaths to relax the abdominal musculature.
Consider this finding as normal, and proceed with the abdominal assessment..
Increase the amount of strength used when attempting to percuss over the abdomen.
Decrease the amount of strength used when attempting to percuss over the abdomen. -
ANSWER Increase the amount of strength used when attempting to percuss over the
abdomen.
A patient has suddenly developed shortness of breath and appears to be in significant
respiratory distress. After calling the physician and placing the patient on oxygen,
which of these actions is the best for the nurse to take when further assessing the
patient?
Count the patient's respirations.
Bilaterally percuss the thorax, noting any differences in percussion tones.
Call for a chest x-ray study, and wait for the results before beginning an
assessment.
Inspect the thorax for any new masses and bleeding associated with respirations. -
ANSWER Bilaterally percuss the thorax, noting any differences in percussion tones.
The nurse is preparing to use a stethoscope for auscultation. Which statement is true
regarding the diaphragm of the stethoscope? The diaphragm:
COMPLETE SOLUTIONS
The nurse is preparing to assess a patient's abdomen by palpation. How should the
nurse proceed?
Palpation of reportedly "tender" areas are avoided because palpation in these areas
may cause pain.
Palpating a tender area is quickly performed to avoid any discomfort that the patient
may experience.
The assessment begins with deep palpation, while encouraging the patient to relax and
to take deep breaths.
The assessment begins with light palpation to detect surface characteristics and to
accustom the patient to being touched. - ANSWER The assessment begins with light
palpation to detect surface characteristics and to accustom the patient to being
touched.
The nurse would use bimanual palpation technique in which situation?
Palpating the thorax of an infant
Palpating the kidneys and uterus
Assessing pulsations and vibrations
Assessing the presence of tenderness and pain - ANSWER Palpating the kidneys and
uterus
The nurse is reviewing percussion techniques with a newly graduated nurse. Which
technique, if used by the new nurse, indicates that more review is needed?
Percussing once over each area
Quickly lifting the striking finger after each stroke
Striking with the fingertip, not the finger pad
Using the wrist to make the strikes, not the arm - ANSWER Percussing once over each
area
, When percussing over the liver of a patient, the nurse notices a dull sound. The nurse
should:
Consider this a normal finding.
Palpate this area for an underlying mass.
Reposition the hands, and attempt to percuss in this area again.
Consider this finding as abnormal, and refer the patient for additional treatment... -
ANSWER Consider this a normal finding.
The nurse is unable to identify any changes in sound when percussing over the
abdomen of an obese patient. What should the nurse do next?
Ask the patient to take deep breaths to relax the abdominal musculature.
Consider this finding as normal, and proceed with the abdominal assessment..
Increase the amount of strength used when attempting to percuss over the abdomen.
Decrease the amount of strength used when attempting to percuss over the abdomen. -
ANSWER Increase the amount of strength used when attempting to percuss over the
abdomen.
A patient has suddenly developed shortness of breath and appears to be in significant
respiratory distress. After calling the physician and placing the patient on oxygen,
which of these actions is the best for the nurse to take when further assessing the
patient?
Count the patient's respirations.
Bilaterally percuss the thorax, noting any differences in percussion tones.
Call for a chest x-ray study, and wait for the results before beginning an
assessment.
Inspect the thorax for any new masses and bleeding associated with respirations. -
ANSWER Bilaterally percuss the thorax, noting any differences in percussion tones.
The nurse is preparing to use a stethoscope for auscultation. Which statement is true
regarding the diaphragm of the stethoscope? The diaphragm:
