NR302: Nursing Skill: Head-to-Chest Assessment
Questions and Answers 100% Accurate
The nurse is admitting a client with an infected left ear cyst. As part of the admission, a head-
to-chest assessment is indicated. Before examining the client, it is important the nurse
completes which nursing actions? Select all that apply. --Correct Answer--Sanitize the
stethoscope end piece with an alcohol swab
Observe the client's face and body language for signs of pain or distress
Ask the client to empty their bladder
Organize supplies to avoid interruptions
Perform hand hygiene
A client-centered health assessment yields both subjective and objective data. The nurse
would ask questions to elicit _______ data and would auscultate heart sounds to elicit ______
data. --Correct Answer--Subjective
Objective
The nurse is inspecting the client's neck. Which three (3) health assessment inspection steps
will the nurse take during the neck examination? --Correct Answer--Observe for symmetry
and midline alignment of the trachea
Observe for masses on the neck
Observe for full range of motion of the neck
, Based on the notes and orders received, the nurse prepares to complete a cardiovascular exam
on the client. Which of these components should be included in the examination? Select all
that apply. --Correct Answer--Palpate pulses
Auscultate carotid arteries
In the table below, choose which supplies are indicated or not indicated for the preparation
for or performance of a head-to-chest assessment. --Correct Answer--Indicated: Clean gloves
Tongue blades
Soap or alcohol-based hand rub
Stethoscope
Not Indicated: Sterile drape
Nurse is auscultating heart sounds and client increases television volume to the max --Correct
Answer--Nurse asks client to lower television volume
Client breath sounds need to be auscultated and the client is in a supine position --Correct
Answer--Client needs to be sitting upright to assess thorax and lungs
Nurse is assessing the skin and finds a mole of irregular shape that client states bleeds
periodically --Correct Answer--Nurse uses ABCDEF mnemonic to assess and refers client to
healthcare provider for follow-up
Nurse asks client to take a deep breath and client grimaces in pain --Correct Answer--Nurse
conducts a focused pain assessment
The nurse in the skill video documented the following after conducting an assessment on the
client. Highlight the incorrect information they documented.
Questions and Answers 100% Accurate
The nurse is admitting a client with an infected left ear cyst. As part of the admission, a head-
to-chest assessment is indicated. Before examining the client, it is important the nurse
completes which nursing actions? Select all that apply. --Correct Answer--Sanitize the
stethoscope end piece with an alcohol swab
Observe the client's face and body language for signs of pain or distress
Ask the client to empty their bladder
Organize supplies to avoid interruptions
Perform hand hygiene
A client-centered health assessment yields both subjective and objective data. The nurse
would ask questions to elicit _______ data and would auscultate heart sounds to elicit ______
data. --Correct Answer--Subjective
Objective
The nurse is inspecting the client's neck. Which three (3) health assessment inspection steps
will the nurse take during the neck examination? --Correct Answer--Observe for symmetry
and midline alignment of the trachea
Observe for masses on the neck
Observe for full range of motion of the neck
, Based on the notes and orders received, the nurse prepares to complete a cardiovascular exam
on the client. Which of these components should be included in the examination? Select all
that apply. --Correct Answer--Palpate pulses
Auscultate carotid arteries
In the table below, choose which supplies are indicated or not indicated for the preparation
for or performance of a head-to-chest assessment. --Correct Answer--Indicated: Clean gloves
Tongue blades
Soap or alcohol-based hand rub
Stethoscope
Not Indicated: Sterile drape
Nurse is auscultating heart sounds and client increases television volume to the max --Correct
Answer--Nurse asks client to lower television volume
Client breath sounds need to be auscultated and the client is in a supine position --Correct
Answer--Client needs to be sitting upright to assess thorax and lungs
Nurse is assessing the skin and finds a mole of irregular shape that client states bleeds
periodically --Correct Answer--Nurse uses ABCDEF mnemonic to assess and refers client to
healthcare provider for follow-up
Nurse asks client to take a deep breath and client grimaces in pain --Correct Answer--Nurse
conducts a focused pain assessment
The nurse in the skill video documented the following after conducting an assessment on the
client. Highlight the incorrect information they documented.
