Nursing 111 - Final Lab Exam Questions
And Answers Latest Update
Respirations at rest - - -
correct answer ✅Ratio of 1 second inspiration to 2 seconds
expiration
Respirations during exertion - - -
correct answer ✅Ratio of 1 second inspiration to 1 second
expiration
Purposes of physical assessment - - -
correct answer ✅Collect baseline data regarding the patient's
health status, validate, build on and/or refute historical data,
reassessments regarding patient's changing health status, evaluate
outcomes of care and predict health risks.
Criteria for an effective physical assessment - - -
correct answer ✅Sufficient light, privacy, quiet, patient comfort
(warm, pain managed, toileting needs met), necessary equipment
available, minimal interruptions and infection control precautions
Items needed to perform a basic physical assessment - - -
correct answer ✅Penlight, lubricant, gloves, stethoscope, alcohol
wipes, scissors, BP cuff, measuring device (side of gauze packet?)
,Nursing 111 - Final Lab Exam Questions
And Answers Latest Update
Techniques of physical assessment - - -
correct answer ✅• Inspection - observations - try not to look just
at the obvious. Don't make assumptions & always to try get
information from the patient
• Palpation - using fingertips, palms or back of hand to make
sensitive assessments like temperature of skin, pain/tenderness,
dry vs. damp skin, unusual lumps, swelling, pulse, capillary refill
• Percussion - produces a vibration that travels through tissues - air
filled organs make a hollow, tympanic sound, dense or fluid filled
organs make a dull sound
• Auscultation - listening to sounds the body makes, usually with a
stethoscope - clothing obscures the sound so place stethoscope
directly on skin surface. Diaphragm (flat) side is best for high pitch
sounds like bowel, breath and normal heart sounds. Bell side is best
for low pitch sounds like extra heart sounds, murmurs.
Different assessment approaches - - -
correct answer ✅Head to toe is a systematic approach used in a
doctor's office (for example) that includes all body systems starting
at the head and working down to the toes. A focused assessment
includes more detail regarding the area or system of concern if
abnormalities are noted or suspected (like focusing on a broken
arm, for example). An emergency assessment is just that and
focuses initially on the ABC's (airway, breathing, circulation).
,Nursing 111 - Final Lab Exam Questions
And Answers Latest Update
Developmental considerations for physical assessments - - -
correct answer ✅For infants and children - a head to toe
assessment will usually not work because the patient won't sit still.
Ask the parents for information. Develop a rapport with the child to
try to communicate with them and incorporate play into the
assessment. Allow children to touch or manipulate equipment.
Encourage the child to talk about their fears or concerns. Do not
conduct painful procedures while the child is on the parent's lap as
children need to know they are safe from painful experiences when
with their parent. The nurse must determine the relationship
between the child and caregiver to ensure that the caregiver can
legally consent to medical treatment. Use age appropriate language
when speaking with the child (i.e. tummy vs. abdomen). Explain
procedures and techniques in word that children can understand.
Begin with the least threatening part of the examination and end
with the most painful or invasive procedure.
For adolescents - assessing adolescents with their parents and then
one-on-one provides a more complete picture and provides the
patient an opportunity to express themselves and discuss concerns
more freely. Develop a rapport with the adolescent and reassure
that the changes happening to their bodies are normal.
Abnormal assessments which require immediate intervention - - -
correct answer ✅Cyanosis, anything that interferes with the ABC's,
enlarged pupils >7mm
, Nursing 111 - Final Lab Exam Questions
And Answers Latest Update
Wheals - - -
correct answer ✅Hives or bites
Papule - - -
correct answer ✅A raised lesion
Macule - - -
correct answer ✅A flat lesion
Vesicle - - -
correct answer ✅A raised lesion w/clear fluid or blood
Pustule - - -
correct answer ✅A raised lesion with pus fluid
Macular-papular - - -
correct answer ✅Raised & flat lesions together
To assess for pallor - - -
correct answer ✅• Check gums, tongue, mucous membranes
• Eyelids or sclera (whites) of eyes
And Answers Latest Update
Respirations at rest - - -
correct answer ✅Ratio of 1 second inspiration to 2 seconds
expiration
Respirations during exertion - - -
correct answer ✅Ratio of 1 second inspiration to 1 second
expiration
Purposes of physical assessment - - -
correct answer ✅Collect baseline data regarding the patient's
health status, validate, build on and/or refute historical data,
reassessments regarding patient's changing health status, evaluate
outcomes of care and predict health risks.
Criteria for an effective physical assessment - - -
correct answer ✅Sufficient light, privacy, quiet, patient comfort
(warm, pain managed, toileting needs met), necessary equipment
available, minimal interruptions and infection control precautions
Items needed to perform a basic physical assessment - - -
correct answer ✅Penlight, lubricant, gloves, stethoscope, alcohol
wipes, scissors, BP cuff, measuring device (side of gauze packet?)
,Nursing 111 - Final Lab Exam Questions
And Answers Latest Update
Techniques of physical assessment - - -
correct answer ✅• Inspection - observations - try not to look just
at the obvious. Don't make assumptions & always to try get
information from the patient
• Palpation - using fingertips, palms or back of hand to make
sensitive assessments like temperature of skin, pain/tenderness,
dry vs. damp skin, unusual lumps, swelling, pulse, capillary refill
• Percussion - produces a vibration that travels through tissues - air
filled organs make a hollow, tympanic sound, dense or fluid filled
organs make a dull sound
• Auscultation - listening to sounds the body makes, usually with a
stethoscope - clothing obscures the sound so place stethoscope
directly on skin surface. Diaphragm (flat) side is best for high pitch
sounds like bowel, breath and normal heart sounds. Bell side is best
for low pitch sounds like extra heart sounds, murmurs.
Different assessment approaches - - -
correct answer ✅Head to toe is a systematic approach used in a
doctor's office (for example) that includes all body systems starting
at the head and working down to the toes. A focused assessment
includes more detail regarding the area or system of concern if
abnormalities are noted or suspected (like focusing on a broken
arm, for example). An emergency assessment is just that and
focuses initially on the ABC's (airway, breathing, circulation).
,Nursing 111 - Final Lab Exam Questions
And Answers Latest Update
Developmental considerations for physical assessments - - -
correct answer ✅For infants and children - a head to toe
assessment will usually not work because the patient won't sit still.
Ask the parents for information. Develop a rapport with the child to
try to communicate with them and incorporate play into the
assessment. Allow children to touch or manipulate equipment.
Encourage the child to talk about their fears or concerns. Do not
conduct painful procedures while the child is on the parent's lap as
children need to know they are safe from painful experiences when
with their parent. The nurse must determine the relationship
between the child and caregiver to ensure that the caregiver can
legally consent to medical treatment. Use age appropriate language
when speaking with the child (i.e. tummy vs. abdomen). Explain
procedures and techniques in word that children can understand.
Begin with the least threatening part of the examination and end
with the most painful or invasive procedure.
For adolescents - assessing adolescents with their parents and then
one-on-one provides a more complete picture and provides the
patient an opportunity to express themselves and discuss concerns
more freely. Develop a rapport with the adolescent and reassure
that the changes happening to their bodies are normal.
Abnormal assessments which require immediate intervention - - -
correct answer ✅Cyanosis, anything that interferes with the ABC's,
enlarged pupils >7mm
, Nursing 111 - Final Lab Exam Questions
And Answers Latest Update
Wheals - - -
correct answer ✅Hives or bites
Papule - - -
correct answer ✅A raised lesion
Macule - - -
correct answer ✅A flat lesion
Vesicle - - -
correct answer ✅A raised lesion w/clear fluid or blood
Pustule - - -
correct answer ✅A raised lesion with pus fluid
Macular-papular - - -
correct answer ✅Raised & flat lesions together
To assess for pallor - - -
correct answer ✅• Check gums, tongue, mucous membranes
• Eyelids or sclera (whites) of eyes
