NUR 275 Exam Study Guide With
Correct Answers.
A nurse is preparing to perform palpation on a client during a physical assessment. Which of the
following findings is the nurse assessing during palpation?
- unexpected sounds made by tapping on the client's skin
- skin temperature, moisture, or unexpected findings
- heart sounds, lung sounds, and bowel sounds
the client's cleanliness and grooming - Answer - skin temperature, moisture, or unexpected
findings
ABCD (And when is this used) - Answer Used in emergency Assessment
-Airway
-Breathing
-Circulation
-Decreased Level of Consciousness (determined by 1. GCS scale, 2. orientation-person, place,
time, event)
ADPIE - Answer -Assessment
-Diagnose
-Planning - figure out a goal
-Implementation - do something to try and achieve that goal
-Evaluation - see if it worked. If not, start over
Anemia - Answer Condition in which the blood does not have enough healthy red blood cells
and hemoglobin, protein found in RBCs to carry oxygen all through the body
Hypoxia - Answer When the tissues in the body do not have enough oxygen to maintain
homeostasis (a stable constant state in the human body)
Cirrhosis - Answer Chronic liver damage leading to scarring and liver failure (hepatitis and
chronic alcohol abuse)
Local trauma - Answer localized exposure to actual or threatened death, serious injury, or
sexual violence
Documenting Blood Pressure: - Answer Which extremity (where on the extremity)
, Their measurement (systolic/diastolic)
If BP is abnormal- try the other arm, implementation of nursing interventions to lower BP, then
reevaluate (ADPIE)(what is the cause of the situation). If the intervention didn't work, go back
and start ADPIE over
Objective Data
Subjective Data - Answer Objective data- data that you observe directly from an interaction
with the patient
Subjective Data- data that the patient tells you; pain, something that happened at home, etc.
Close ended statements
Open ended statements - Answer close ended allows for yes/no questions, open ended
allows for elaboration. not yes/no answer
If a patient is experiencing pain but is having trouble describing it to you, what nursing
intervention do you take? - Answer Give them choices of descriptive words. Is is sharp, dull,
burning, etc.
Review of Systems (exam) - Answer It's a subjective assessment of the patient's perceived
symptoms, and is often structured as a component of an admission note. A ROS can include
constitutional symptoms, such as fever or weight loss, as well as systems like the eyes, ears,
nose, mouth, throat, cardiovascular, respiratory, gastrointestinal, and genitourinary.
Physical exam - Answer A PE is a descriptive review of the findings from a physical
examination, without interpretation. It's an objective assessment that focuses on preventive
care and overall health. A PE can involve visual or hands-on findings, such as using an otoscope
to inspect the middle ear, an ophthalmoscope to check the eyes, or a stethoscope to listen to
heart, lung, and bowel sounds.
How do you physically check skin temp - Answer Dorsal side of hand
What finger(s), and what part of the finger do you use to check pulse or skin lesions? - Answer
tips of the first three fingers
When do you use the bell of the stethoscope - Answer Low frequency sounds- Peds, carotid
assessment, heart murmurs and bruits (cardiovascular) (touching skin)
when do you use the diaphragm of the stethoscope - Answer High frequency sounds- bowel
and lung sounds (touching skin)
Correct Answers.
A nurse is preparing to perform palpation on a client during a physical assessment. Which of the
following findings is the nurse assessing during palpation?
- unexpected sounds made by tapping on the client's skin
- skin temperature, moisture, or unexpected findings
- heart sounds, lung sounds, and bowel sounds
the client's cleanliness and grooming - Answer - skin temperature, moisture, or unexpected
findings
ABCD (And when is this used) - Answer Used in emergency Assessment
-Airway
-Breathing
-Circulation
-Decreased Level of Consciousness (determined by 1. GCS scale, 2. orientation-person, place,
time, event)
ADPIE - Answer -Assessment
-Diagnose
-Planning - figure out a goal
-Implementation - do something to try and achieve that goal
-Evaluation - see if it worked. If not, start over
Anemia - Answer Condition in which the blood does not have enough healthy red blood cells
and hemoglobin, protein found in RBCs to carry oxygen all through the body
Hypoxia - Answer When the tissues in the body do not have enough oxygen to maintain
homeostasis (a stable constant state in the human body)
Cirrhosis - Answer Chronic liver damage leading to scarring and liver failure (hepatitis and
chronic alcohol abuse)
Local trauma - Answer localized exposure to actual or threatened death, serious injury, or
sexual violence
Documenting Blood Pressure: - Answer Which extremity (where on the extremity)
, Their measurement (systolic/diastolic)
If BP is abnormal- try the other arm, implementation of nursing interventions to lower BP, then
reevaluate (ADPIE)(what is the cause of the situation). If the intervention didn't work, go back
and start ADPIE over
Objective Data
Subjective Data - Answer Objective data- data that you observe directly from an interaction
with the patient
Subjective Data- data that the patient tells you; pain, something that happened at home, etc.
Close ended statements
Open ended statements - Answer close ended allows for yes/no questions, open ended
allows for elaboration. not yes/no answer
If a patient is experiencing pain but is having trouble describing it to you, what nursing
intervention do you take? - Answer Give them choices of descriptive words. Is is sharp, dull,
burning, etc.
Review of Systems (exam) - Answer It's a subjective assessment of the patient's perceived
symptoms, and is often structured as a component of an admission note. A ROS can include
constitutional symptoms, such as fever or weight loss, as well as systems like the eyes, ears,
nose, mouth, throat, cardiovascular, respiratory, gastrointestinal, and genitourinary.
Physical exam - Answer A PE is a descriptive review of the findings from a physical
examination, without interpretation. It's an objective assessment that focuses on preventive
care and overall health. A PE can involve visual or hands-on findings, such as using an otoscope
to inspect the middle ear, an ophthalmoscope to check the eyes, or a stethoscope to listen to
heart, lung, and bowel sounds.
How do you physically check skin temp - Answer Dorsal side of hand
What finger(s), and what part of the finger do you use to check pulse or skin lesions? - Answer
tips of the first three fingers
When do you use the bell of the stethoscope - Answer Low frequency sounds- Peds, carotid
assessment, heart murmurs and bruits (cardiovascular) (touching skin)
when do you use the diaphragm of the stethoscope - Answer High frequency sounds- bowel
and lung sounds (touching skin)
