NR-302 Initial Physical Assessment Exam 2 NCLEX Questions and Answers 2023/2024

NR-302 Initial Physical Assessment Exam 2 NCLEX Questions and Answers 2023/2024 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 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 - 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