NR 302 Cumulative Test
Assessment Environment - correct answer ✔✔Room should be warm, comfortable, quiet, and private.
It should be a clean and safe environment.
Safety should also be from nosocomial infections and should use standard precautions as well.
Assessment done in this order................except for an abdominal assessment - correct answer
✔✔Inspection - watching
Palpation - touch with fingers
Percussion - tapping
Auscultation - listening
(Abdominal it is auscultation before palpation and percussion)
Palpation can assess - correct answer ✔✔Temperature/ moisture - dorsal side of hand
Texture
Vibration or pulsations
Rigidity/ spasticity
Crepitation or crackles
Swelling/ edema
Organ location
Lumps/ masses
Tenderness/ pain
Indirect Percussion - correct answer ✔✔Is the finger tap thing that doesn't really do anything, but if you
want the what the slide says.
Pleximeter
Non-dominant middle finger
,Makes firm contact with the body (lung, abdomen)
Plexor finger delivers 2 sharp strikes
Use tip of finger, NOT finger pad to delivery the blow.
Tympany - correct answer ✔✔Loud, high-pitched, medium, drum-like
Organ filled with air - intestines, stomach
Resonance - correct answer ✔✔Loud, low-pitched, long
Lungs
Hyperresonance - correct answer ✔✔Loud, low-pitched, longer
Lungs (air trapped - emphysema)
Dullness - correct answer ✔✔High-pitched, soft, short
Solid organs (liver, spleen, tumors)
Flatness - correct answer ✔✔High-pitched, very soft, very short
Solid tissue (muscle, bone)
Direct Percussion - correct answer ✔✔Using your finger tips to tap on the body, like taping on a fish
tank.
Technique to assess
Sinuses of an adult
Thorax of an infant
Blunt Percussion - correct answer ✔✔Used for assessing pain and tenderness
Gallbladder
,Liver
Kidney
Costovertebral angle (CVA) tenderness
Kidney infection
Auscultation Sounds - correct answer ✔✔Intensity
Pitch
High-Pitched (diaPHragm of stethoscope)
Breath sounds, heart sounds, bowel sounds
Low-pitched (beLL of stethoscope)
Abnormal heart sounds, vascular sounds (bruits)
Duration
Quality
BeLL - Light and Low
DiapHragm - Deep and High
OPhthalmoscope - correct answer ✔✔Eyes
OToscope - correct answer ✔✔Ears
Nose
General Survey is... - correct answer ✔✔NO TOUCHING!!!
It is using your senses (the grocery shopping thing)
Vision
Hearing
Smell
General Survery
, LOC, orientation - correct answer ✔✔Alert; Person, place, time, and situation
General Survery
Gait - correct answer ✔✔Steady, smooth, opposing arm swings
General Survery
Posture, position, obvious physical deformities - correct answer ✔✔Erect, w/o physical deformities
General Survery
Facial expression, speech - correct answer ✔✔Appropriate to situation, relaxed, clear, & understandable
General Survery
Hygiene - correct answer ✔✔Clean, no odors
BMI - Body Mass Index - correct answer ✔✔More reliable indicator of healthy weight
19-24 (healthy weight)
25-29 (overweight)
> 30 (obese range)
Weight - correct answer ✔✔Round up Randy.....with the weight measurements.
Instruct the patient to take off:
Shoes
Outer clothing (jacket, sweater, scarf)
Sequence weight: (Same scale)
Same time of day
Same clothing
Record weight in both Kg's & pounds