NR-302 EXAM 2 NCLEX QUESTIONS AND
ANSWERS WITH COMPLETE SOLUTIONS 100%
CORRECT RATED A+
The nurse is preparing to assess a 55-year-old female. Which of the following will
the nurse do first?
Inspection
Percussion
Palpation
Auscultation -ANSWER ✔✔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 information about this
complaint?
Inspection
Percussion
Palpation
Auscultation -ANSWER ✔✔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.
This area should be palpated last.
This area should be assessed using deep palpation techniques.
This area should not be palpated. -ANSWER ✔✔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
pinktinged urine. Which of the following assessment techniques would be
appropriate for the nurse to use?
Direct percussion
Reflexive percussion
Indirect percussion
, Blunt percussion -ANSWER ✔✔Blunt percussion
Blunt percussion is used for assessing pain and tenderness in the 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
ANSWERS WITH COMPLETE SOLUTIONS 100%
CORRECT RATED A+
The nurse is preparing to assess a 55-year-old female. Which of the following will
the nurse do first?
Inspection
Percussion
Palpation
Auscultation -ANSWER ✔✔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 information about this
complaint?
Inspection
Percussion
Palpation
Auscultation -ANSWER ✔✔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.
This area should be palpated last.
This area should be assessed using deep palpation techniques.
This area should not be palpated. -ANSWER ✔✔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
pinktinged urine. Which of the following assessment techniques would be
appropriate for the nurse to use?
Direct percussion
Reflexive percussion
Indirect percussion
, Blunt percussion -ANSWER ✔✔Blunt percussion
Blunt percussion is used for assessing pain and tenderness in the 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
