NUR 3065 COMPLETE PREP U
CHAPTER 6 BASED QUESTIONS AND
ANSWERS
In the course of performing a client's physical assessment, the nurse has changed from using the
diaphragm of the stethoscope to using the bell. The nurse is most likely assessing which of the following?
Femoral pulses
Heart sounds
Breath sounds
Bowel sounds - ANS-✅Heart sounds
Explanation:
The bell of the stethoscope is used to listen to low-pitched sounds such as abnormal heart sounds (heart
murmurs) and bruits. The diaphragm is used to listen for high-pitched sounds such as normal heart
sounds, breath sounds, bowel sounds, and pulses.
When assessing a client, the first skill used is inspection. What purpose does inspection serve?
Gathering information
Observing modesty
Identifying internal abnormalities
Feeling abnormalities - ANS-✅Gathering information
Explanation:
Inspection is the first technique of the overall general survey and for each body part, because it provides
so much general information. Inspection is the one technique that is performed for every body part and
body system. During inspection, the nurse does not use the hands to feel anything. Inspection is not to
observe the client's modesty or to identify anything internal. Feeling some abnormalities and identifying
some internal abnormalities would not be inspection but rather palpation. Inspection does not help with
observing modesty.
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?
Snellen chart
Cover card
Ophthalmoscope
Rosenbaum pocket screener - ANS-✅Snellen chart
Explanation:
To check the client's distant vision the nurse should use the Snellen chart. An ophthalmoscope is used to
view the red reflex and examine the retina of the eye. A cover card is used to test for strabismus. A
newspaper or Rosenbaum pocket screener is used to test near vision.
While performing the physical examination of a client, the nurse lightly taps certain parts of the body to
produce sound waves. What is the purpose of this method of assessment?
Determine tenderness, moisture, and the surface of skin texture
, Observe for abnormalities on the skin's surface
Determine if a structure is filled with air or fluid or is a solid structure
Feel for deep organs or structures covered by thick muscles - ANS-✅Determine if a structure is filled
with air or fluid or is a solid structure
Explanation:
The nurse uses the percussion technique while performing a physical examination in order to determine
whether the underlying structure is filled with air or fluid or is a solid structure. Palpation technique is
used to feel deep organs or structures covered by thick muscles, and to determine tenderness, moisture,
and surface of skin texture. The nurse uses the inspection technique to look for abnormalities on the
skin's surface.
In which order should a nurse implement the four physical assessment techniques when initiating a
health assessment?
Auscultation, percussion, palpation, inspection
Inspection, auscultation, percussion, palpation
Inspection, palpation, percussion, auscultation
Percussion, palpation, inspection, auscultation - ANS-✅Inspection, palpation, percussion, auscultation
Explanation:
Inspection is the first physical assessment technique that a nurse should implement. This prevents
altering the appearance of structures that may distract the nurse from completing a focused
observation.
It is recommended that a left-handed examiner adopt a right-sided position.
True
False - ANS-✅True
The nurse is caring for the client who is receiving heparin. The nurse plans to:
Recap the needle after administering heparin to the client
Wear a mask when administering heparin to the client
Wear clean gloves when administering heparin to the client
Perform hand hygiene with alcohol-based gel after administering the heparin - ANS-✅Wear clean gloves
when administering heparin to the client
Explanation:
Heparin is an anticoagulant administered subcutaneously in the abdomen, which may expose the nurse
to direct contact with the client's body fluids. The nurse wears clean gloves when administering heparin
and after administering the heparin does not recap the needle and performs hand hygiene with alcohol-
based gel. A mask is not required when administering heparin to the client.
Which describes the nurse using the technique of percussion?
The nurse detects rustling over the individual's thorax.
The nurse detects crepitus over the individual's thorax.
The nurse notes resonance over the individual's thorax.
The nurse notes symmetry of the individual's thorax. - ANS-✅The nurse notes resonance over the
individual's thorax.
CHAPTER 6 BASED QUESTIONS AND
ANSWERS
In the course of performing a client's physical assessment, the nurse has changed from using the
diaphragm of the stethoscope to using the bell. The nurse is most likely assessing which of the following?
Femoral pulses
Heart sounds
Breath sounds
Bowel sounds - ANS-✅Heart sounds
Explanation:
The bell of the stethoscope is used to listen to low-pitched sounds such as abnormal heart sounds (heart
murmurs) and bruits. The diaphragm is used to listen for high-pitched sounds such as normal heart
sounds, breath sounds, bowel sounds, and pulses.
When assessing a client, the first skill used is inspection. What purpose does inspection serve?
Gathering information
Observing modesty
Identifying internal abnormalities
Feeling abnormalities - ANS-✅Gathering information
Explanation:
Inspection is the first technique of the overall general survey and for each body part, because it provides
so much general information. Inspection is the one technique that is performed for every body part and
body system. During inspection, the nurse does not use the hands to feel anything. Inspection is not to
observe the client's modesty or to identify anything internal. Feeling some abnormalities and identifying
some internal abnormalities would not be inspection but rather palpation. Inspection does not help with
observing modesty.
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?
Snellen chart
Cover card
Ophthalmoscope
Rosenbaum pocket screener - ANS-✅Snellen chart
Explanation:
To check the client's distant vision the nurse should use the Snellen chart. An ophthalmoscope is used to
view the red reflex and examine the retina of the eye. A cover card is used to test for strabismus. A
newspaper or Rosenbaum pocket screener is used to test near vision.
While performing the physical examination of a client, the nurse lightly taps certain parts of the body to
produce sound waves. What is the purpose of this method of assessment?
Determine tenderness, moisture, and the surface of skin texture
, Observe for abnormalities on the skin's surface
Determine if a structure is filled with air or fluid or is a solid structure
Feel for deep organs or structures covered by thick muscles - ANS-✅Determine if a structure is filled
with air or fluid or is a solid structure
Explanation:
The nurse uses the percussion technique while performing a physical examination in order to determine
whether the underlying structure is filled with air or fluid or is a solid structure. Palpation technique is
used to feel deep organs or structures covered by thick muscles, and to determine tenderness, moisture,
and surface of skin texture. The nurse uses the inspection technique to look for abnormalities on the
skin's surface.
In which order should a nurse implement the four physical assessment techniques when initiating a
health assessment?
Auscultation, percussion, palpation, inspection
Inspection, auscultation, percussion, palpation
Inspection, palpation, percussion, auscultation
Percussion, palpation, inspection, auscultation - ANS-✅Inspection, palpation, percussion, auscultation
Explanation:
Inspection is the first physical assessment technique that a nurse should implement. This prevents
altering the appearance of structures that may distract the nurse from completing a focused
observation.
It is recommended that a left-handed examiner adopt a right-sided position.
True
False - ANS-✅True
The nurse is caring for the client who is receiving heparin. The nurse plans to:
Recap the needle after administering heparin to the client
Wear a mask when administering heparin to the client
Wear clean gloves when administering heparin to the client
Perform hand hygiene with alcohol-based gel after administering the heparin - ANS-✅Wear clean gloves
when administering heparin to the client
Explanation:
Heparin is an anticoagulant administered subcutaneously in the abdomen, which may expose the nurse
to direct contact with the client's body fluids. The nurse wears clean gloves when administering heparin
and after administering the heparin does not recap the needle and performs hand hygiene with alcohol-
based gel. A mask is not required when administering heparin to the client.
Which describes the nurse using the technique of percussion?
The nurse detects rustling over the individual's thorax.
The nurse detects crepitus over the individual's thorax.
The nurse notes resonance over the individual's thorax.
The nurse notes symmetry of the individual's thorax. - ANS-✅The nurse notes resonance over the
individual's thorax.
