NR-302 Exam 2 NCLEX questions with
answers
The nurse is preparing to assess a 55-year-old female. Which of the
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
following will the nurse do first?
|/\ |/\ |/\ |/\ |/\ |/\
|/\
|/\ Inspection
|/\ Percussion
|/\ Palpation
|/\ Auscultation - |/\ |/\ CORRECT ANSWERS ✔✔Inspection |/\ |/\
|/\ Inspection always precedes the other assessment skills and is
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
never rushed. The order of assessment techniques is: inspection,
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
palpation, percussion, and auscultation, except when assessing the
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
abdomen, where the techniques are inspection, auscultation,
|/\ |/\ |/\ |/\ |/\ |/\ |/\
percussion, and palpation.
|/\ |/\ |/\ |/\
Nursing Process: Planning |/\ |/\
Cognitive Level: Comprehension |/\ |/\
Client Need: Physiological Integrity
|/\ |/\ |/\
A client comes into the clinic with the complaint of swollen ankles.
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
The nurse will utilize which assessment technique to find out more
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
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, information about this complaint?
|/\ |/\ |/\ |/\
|/\
|/\ Inspection
|/\ Percussion
|/\ Palpation
|/\ Auscultation - |/\ |/\ CORRECT ANSWERS ✔✔Palpation |/\ |/\
|/\ Palpation is the use of touch to assess specific body characteristics,
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
which include size, shape, location, mobility, position, vibration,
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
temperature, texture, moisture, tenderness, and edema. Palpating
|/\ |/\ |/\ |/\ |/\ |/\ |/\
the ankle will give the nurse information about tenderness,
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
temperature, mobility, and edema characteristics. Visual
|/\ |/\ |/\ |/\ |/\ |/\
inspection is also included in the assessment of the ankles, but
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
palpation will yield the most information. Percussion and
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
auscultation are not techniques used to assess the ankles.
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
Nursing Process: Assessment |/\ |/\
Cognitive Level: Synthesis |/\ |/\
Client Need: Physiological Integrity
|/\ |/\ |/\
A client comes into the clinic with acute right lower quadrant
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
abdominal pain. During the abdominal assessment of this client,
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
the nurse realizes that:
|/\ |/\ |/\ |/\
|/\
|/\ This area should be palpated first.
|/\ |/\ |/\ |/\ |/\
2
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,|/\ This area should be palpated last.
|/\ |/\ |/\ |/\ |/\
|/\ This area should be assessed using deep palpation techniques.
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
|/\ This area should not be palpated. -
|/\ |/\ |/\ |/\ |/\ |/\ |/\ CORRECT ANSWERS ✔✔This |/\ |/\
area should be palpated last.
|/\ |/\ |/\ |/\ |/\
|/\
Known-painful areas of the body are usually the last areas to be |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
palpated. Deep palpation should be used with caution, especially if
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
one suspects that there is inflammation, peritonitis, or ectopic
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
pregnancy. The area should be assessed using light to moderate
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
palpation.
|/\ |/\
Nursing Process: Planning |/\ |/\
Cognitive Level: Application |/\ |/\
Client Need: Physiological Integrity
|/\ |/\ |/\
The nurse is preparing to assess a client with flank pain and
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
discomfort and pink-tinged urine. Which of the following
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
assessment techniques would be appropriate for the nurse to use?
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
|/\
|/\ Direct percussion |/\
|/\ Reflexive percussion |/\
|/\ Indirect percussion |/\
|/\ Blunt percussion -
|/\ |/\ |/\ CORRECT ANSWERS ✔✔Blunt percussion |/\ |/\ |/\
|/\ Blunt percussion is used for assessing pain and tenderness in the
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
3
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, gallbladder, liver, and kidneys. With blunt percussion, the palm of
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
the nondominant hand is flat against the body and a closed fist is
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
used to strike the hand on the body. Direct percussion is tapping
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
the body directly to examine the sinuses or the thorax of an infant.
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
Reflexive percussion is not an assessment technique. Indirect
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
percussion is the most common method used to produce sounds
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
within the body. To perform indirect percussion, the middle finger
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
of the nondominant hand is placed firmly over the area being
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
examined. The middle finger of the dominant hand quickly strikes
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
the middle finger of the nondominant hand, producing vibrations
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
and a sound.
|/\ |/\ |/\ |/\
Nursing Process: Assessment |/\ |/\
Cognitive Level: Application |/\ |/\
Client Need: Physiological Integrity
|/\ |/\ |/\
During the percussion of a client's abdomen, the nurse hears a loud,
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
high-pitched, drumlike tone. The nurse would document this
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
sound as being:
|/\ |/\ |/\
|/\
|/\ Resonance
|/\ Hyperresonance
|/\ Tympany
|/\ Flatness - |/\ |/\ CORRECT ANSWERS ✔✔Tympany |/\ |/\
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answers
The nurse is preparing to assess a 55-year-old female. Which of the
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
following will the nurse do first?
|/\ |/\ |/\ |/\ |/\ |/\
|/\
|/\ Inspection
|/\ Percussion
|/\ Palpation
|/\ Auscultation - |/\ |/\ CORRECT ANSWERS ✔✔Inspection |/\ |/\
|/\ Inspection always precedes the other assessment skills and is
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
never rushed. The order of assessment techniques is: inspection,
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
palpation, percussion, and auscultation, except when assessing the
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
abdomen, where the techniques are inspection, auscultation,
|/\ |/\ |/\ |/\ |/\ |/\ |/\
percussion, and palpation.
|/\ |/\ |/\ |/\
Nursing Process: Planning |/\ |/\
Cognitive Level: Comprehension |/\ |/\
Client Need: Physiological Integrity
|/\ |/\ |/\
A client comes into the clinic with the complaint of swollen ankles.
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
The nurse will utilize which assessment technique to find out more
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
1
\\\\\\
|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\
/
|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\ \\\\
, information about this complaint?
|/\ |/\ |/\ |/\
|/\
|/\ Inspection
|/\ Percussion
|/\ Palpation
|/\ Auscultation - |/\ |/\ CORRECT ANSWERS ✔✔Palpation |/\ |/\
|/\ Palpation is the use of touch to assess specific body characteristics,
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
which include size, shape, location, mobility, position, vibration,
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
temperature, texture, moisture, tenderness, and edema. Palpating
|/\ |/\ |/\ |/\ |/\ |/\ |/\
the ankle will give the nurse information about tenderness,
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
temperature, mobility, and edema characteristics. Visual
|/\ |/\ |/\ |/\ |/\ |/\
inspection is also included in the assessment of the ankles, but
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
palpation will yield the most information. Percussion and
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
auscultation are not techniques used to assess the ankles.
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
Nursing Process: Assessment |/\ |/\
Cognitive Level: Synthesis |/\ |/\
Client Need: Physiological Integrity
|/\ |/\ |/\
A client comes into the clinic with acute right lower quadrant
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
abdominal pain. During the abdominal assessment of this client,
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
the nurse realizes that:
|/\ |/\ |/\ |/\
|/\
|/\ This area should be palpated first.
|/\ |/\ |/\ |/\ |/\
2
\\\\\\
|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\
/
|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\ \\\\
,|/\ This area should be palpated last.
|/\ |/\ |/\ |/\ |/\
|/\ This area should be assessed using deep palpation techniques.
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
|/\ This area should not be palpated. -
|/\ |/\ |/\ |/\ |/\ |/\ |/\ CORRECT ANSWERS ✔✔This |/\ |/\
area should be palpated last.
|/\ |/\ |/\ |/\ |/\
|/\
Known-painful areas of the body are usually the last areas to be |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
palpated. Deep palpation should be used with caution, especially if
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
one suspects that there is inflammation, peritonitis, or ectopic
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
pregnancy. The area should be assessed using light to moderate
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
palpation.
|/\ |/\
Nursing Process: Planning |/\ |/\
Cognitive Level: Application |/\ |/\
Client Need: Physiological Integrity
|/\ |/\ |/\
The nurse is preparing to assess a client with flank pain and
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
discomfort and pink-tinged urine. Which of the following
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
assessment techniques would be appropriate for the nurse to use?
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
|/\
|/\ Direct percussion |/\
|/\ Reflexive percussion |/\
|/\ Indirect percussion |/\
|/\ Blunt percussion -
|/\ |/\ |/\ CORRECT ANSWERS ✔✔Blunt percussion |/\ |/\ |/\
|/\ Blunt percussion is used for assessing pain and tenderness in the
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
3
\\\\\\
|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\
/
|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\|/\ \\\\
, gallbladder, liver, and kidneys. With blunt percussion, the palm of
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
the nondominant hand is flat against the body and a closed fist is
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
used to strike the hand on the body. Direct percussion is tapping
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
the body directly to examine the sinuses or the thorax of an infant.
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
Reflexive percussion is not an assessment technique. Indirect
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
percussion is the most common method used to produce sounds
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
within the body. To perform indirect percussion, the middle finger
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
of the nondominant hand is placed firmly over the area being
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
examined. The middle finger of the dominant hand quickly strikes
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
the middle finger of the nondominant hand, producing vibrations
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
and a sound.
|/\ |/\ |/\ |/\
Nursing Process: Assessment |/\ |/\
Cognitive Level: Application |/\ |/\
Client Need: Physiological Integrity
|/\ |/\ |/\
During the percussion of a client's abdomen, the nurse hears a loud,
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
high-pitched, drumlike tone. The nurse would document this
|/\ |/\ |/\ |/\ |/\ |/\ |/\ |/\
sound as being:
|/\ |/\ |/\
|/\
|/\ Resonance
|/\ Hyperresonance
|/\ Tympany
|/\ Flatness - |/\ |/\ CORRECT ANSWERS ✔✔Tympany |/\ |/\
4
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/
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