C HAPTER 2: E VALUATING C LINICAL
E VIDENCE
MULTIPLE CHOICE
1. The nurse is unable to palpate the right radial pulse on a patient. The best
action would be to:
a. Auscultate over the area with a fetoscope.
b. Use a goniometer to measure the pulsations.
c. Use a Doppler device to check for pulsations over the area.
d. Check for the presence of pulsations with a stethoscope.
ANS: C
Doppler devices are used to augment pulse or blood pressure
measurements. Goniometers meas ure joint range of motion. A
fetoscope is used to auscultate fetal heart tones. Stethoscopes are used
to auscultate breath, bowel, and heart sounds.
DIF: Cognitive Level: Anal yzing (Anal ysis) REF: p. 120
MSC: Client Needs: Safe and Effective Care Enviro nment:
Management of Care
2. The nurse is preparing to perform a physical assessment. The correct
action by the nurse is reflected by which statement? The nurse:
a. Performs the examination from the left side of the bed.
, b. Examines tender or painful areas first to help relieve the patients
anxiet y.
c. Follows the same examination sequence, regardless of the patients
age or condition.
d. Organizes the assessment to ensure that the patient does not change
positions too often.
ANS: D
The steps of the assessment shoul d be organized to ensure that the
patient does not change positions too often. The sequence of the steps
of the assessment may differ, depending on the age of the person and
the examiners preference. Tender or painful areas should be assessed
last.
DIF: Cognitive Level: Appl ying (Application) REF: p. 121 MSC:
Client Needs: Safe and Effective Care Environment: Management of
Care
3. A man is at the clinic for a physical examination. He states that he is very
anxious about the physical examination. What steps can the nurse take to
make him more comfortable?
a. Appear unhurried and confident when examining him.
b. Stay in the room when he undresses in case he needs assistance.
c. Ask him to change into an examining gown and to take off his
undergarments.
d. Defer measuring vital signs until the end of the examination, which
allows him time to become comfortable.
ANS: A
, Anxiet y can be reduced by an examiner who is confident, self -assured,
considerate, and unhurried. Familiar and relativel y nonthreatening
actions, such as me asuring the persons vital signs, will graduall y
accustom the person to the examination.
DIF: Cognitive Level: Appl ying (Application) REF: p. 121 MSC:
Client Needs: Safe and Effective Care Environment: Management of
Care
4. When performing a physical examin ation, safet y must be considered to
protect the examiner and the patient against the spread of infection. Which
of these statements describes the most appropriate action the nurse should
take when performing a physical examination?
a. Washing ones hands after removing gloves is not necessary, as long
as the gloves are still intact.
b. Hands are washed before and after every physical patient encounter.
c. Hands are washed before the examination of each body system to
prevent the spread of bacteria from one part of th e body to another.
d. Gloves are worn throughout the entire examination to demonstrate
to the patient concern regarding the spread of infectious diseases.
ANS: B
The nurse should wash his or her hands before and after every physical
patient encounter; after contact with blood, body fluids, secretions, and
excretions; after contact with any equipment contaminated with body
fluids; and after removing gloves. Hands should be washed after gloves
have been removed, even if the gloves appear to be intact. Gloves
should be worn when potential contact with any body fluids is present.
E VIDENCE
MULTIPLE CHOICE
1. The nurse is unable to palpate the right radial pulse on a patient. The best
action would be to:
a. Auscultate over the area with a fetoscope.
b. Use a goniometer to measure the pulsations.
c. Use a Doppler device to check for pulsations over the area.
d. Check for the presence of pulsations with a stethoscope.
ANS: C
Doppler devices are used to augment pulse or blood pressure
measurements. Goniometers meas ure joint range of motion. A
fetoscope is used to auscultate fetal heart tones. Stethoscopes are used
to auscultate breath, bowel, and heart sounds.
DIF: Cognitive Level: Anal yzing (Anal ysis) REF: p. 120
MSC: Client Needs: Safe and Effective Care Enviro nment:
Management of Care
2. The nurse is preparing to perform a physical assessment. The correct
action by the nurse is reflected by which statement? The nurse:
a. Performs the examination from the left side of the bed.
, b. Examines tender or painful areas first to help relieve the patients
anxiet y.
c. Follows the same examination sequence, regardless of the patients
age or condition.
d. Organizes the assessment to ensure that the patient does not change
positions too often.
ANS: D
The steps of the assessment shoul d be organized to ensure that the
patient does not change positions too often. The sequence of the steps
of the assessment may differ, depending on the age of the person and
the examiners preference. Tender or painful areas should be assessed
last.
DIF: Cognitive Level: Appl ying (Application) REF: p. 121 MSC:
Client Needs: Safe and Effective Care Environment: Management of
Care
3. A man is at the clinic for a physical examination. He states that he is very
anxious about the physical examination. What steps can the nurse take to
make him more comfortable?
a. Appear unhurried and confident when examining him.
b. Stay in the room when he undresses in case he needs assistance.
c. Ask him to change into an examining gown and to take off his
undergarments.
d. Defer measuring vital signs until the end of the examination, which
allows him time to become comfortable.
ANS: A
, Anxiet y can be reduced by an examiner who is confident, self -assured,
considerate, and unhurried. Familiar and relativel y nonthreatening
actions, such as me asuring the persons vital signs, will graduall y
accustom the person to the examination.
DIF: Cognitive Level: Appl ying (Application) REF: p. 121 MSC:
Client Needs: Safe and Effective Care Environment: Management of
Care
4. When performing a physical examin ation, safet y must be considered to
protect the examiner and the patient against the spread of infection. Which
of these statements describes the most appropriate action the nurse should
take when performing a physical examination?
a. Washing ones hands after removing gloves is not necessary, as long
as the gloves are still intact.
b. Hands are washed before and after every physical patient encounter.
c. Hands are washed before the examination of each body system to
prevent the spread of bacteria from one part of th e body to another.
d. Gloves are worn throughout the entire examination to demonstrate
to the patient concern regarding the spread of infectious diseases.
ANS: B
The nurse should wash his or her hands before and after every physical
patient encounter; after contact with blood, body fluids, secretions, and
excretions; after contact with any equipment contaminated with body
fluids; and after removing gloves. Hands should be washed after gloves
have been removed, even if the gloves appear to be intact. Gloves
should be worn when potential contact with any body fluids is present.
