A) Snellen - ✔✔The nurse is performing a vision examination. Which of these charts is most
widely used for vision examinations?
a. Snellen
b. Shetllen
c. Smoollen
d. Schwellon
d) Consider this a normal finding for a child this age and proceed with the examination. -
✔✔The nurse hears bilateral louder, longer, and lower tones when percussing over thelungs of a
4-year old child. What should the nurse do next?
a. Palpate over the area for increased pain and tenderness.
b. Ask the child to take shallow breaths and percuss over the area again.
c. Refer the child immediately because of an increased amount of air in the lungs.
d. Consider this a normal finding for a child this age and proceed with the examination.
b) Percuss the thorax bilaterally, noting any differences in percussion tones. - ✔✔Apatient has
suddenly developed shortness of breath and appears to be in significant respiratory distress. After
putting a call in to the physician and placing the patient onoxygen, which of these is the best
action for the nurse to take when assessing the patient further?
a. Count the patient's respirations.
b. Percuss the thorax bilaterally, noting any differences in percussion tones.
c. Call for a chest x-ray and wait for the results before beginning an assessment.
d. Inspect the thorax for any new masses and bleeding associated with respirations.
b) The stethoscope does not magnify sound but does block out extraneous room noise.✔✔The
nurse is teaching a class on basic assessment skills. Which of these statements is true regarding
the stethoscope and its use?
a. The slope of the earpieces should point posteriorly (toward the occiput).
b. The stethoscope does not magnify sound but does block out extraneous room noise.
c. The fit and quality of the stethoscope are not as important as its ability to magnify sound.
d. The ideal tubing length should be 22 inches to dampen distortion of sound.
,a) The diaphragm is used to listen for high-pitched sounds. - ✔✔The nurse is preparingto use a
stethoscope for auscultation. Which statement is true regarding the diaphragm of the
stethoscope?
a. The diaphragm is used to listen for high-pitched sounds.
b. The diaphragm is used to listen for low-pitched sounds.
c. The diaphragm should be held lightly against the person's skin to block out low-pitched
sounds.
d. The diaphragm should be held lightly against the person's skin to listen for extra heart sounds
and murmurs.
d) Check the temperature of the room and offer blankets to the patient if he or she feelscold -
✔✔Before auscultating the abdomen for the presence of bowel sounds on a patient, the nurse
should:
a. Warm the end piece of the stethoscope by placing it in warm water
b. Leave the gown on so that the patient does not get chilled during the examination
c. Make sure that the bell side of the stethoscope is turned to the "on" position
d. Check the temperature of the room and offer blankets to the patient if he or she feelscold
a) Palpation - ✔✔The nurse will use which technique of assessment to determine the presence of
crepitus, swelling, and pulsations?
a) Palpation
b) Inspection
c. Percussion
d) Auscultation
The otoscope directs light into the ear canal and onto the tympanic membrane. -
✔✔The nurse is preparing to use an otoscope for an examination. Which statement istrue
regarding the otoscope?
a. The otoscope is often used to direct light onto the sinuses.
b. The otoscope uses a short, broad speculum to help visualize the ear.
c. The otoscope is used to examine the structures of the internal ear.
d. The otoscope directs light into the ear canal and onto the tympanic membrane.
d) Rotating the lens selector dial to bring the object into focus - ✔✔An examiner is using an
ophthalmoscope to examine a patient's eyes. The patient has astigmatism and is nearsighted. The
use of which of these techniques would indicate that theexamination is being performed
correctly?
, a. Using the large full circle of light when assessing pupils that are not dilated
b. Rotating the lens selector dial to the black numbers to compensate for astigmatism
c. Using the grid on the lens aperture dial to visualize the external structures of the eye
d. Rotating the lens selector dial to bring the object into focus
c) Use a Doppler device to check for pulsations over the area - ✔✔The nurse is unableto 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
d) The nurse organizes the assessment so that the patient does not change positions too often. -
✔✔The nurse is preparing to perform a physical assessment. The correct action by the nurse is
reflected by which statement?
a. The nurse performs the examination from the left side of the bed.
b. The nurse examines tender or painful areas first to help relieve the patient's anxiety.
c. The nurse follows the same examination sequence regardless of the patient's age or condition.
d. The nurse organizes the assessment so that the patient does not change positions too often.
a) Appear unhurried and confident when examining him. - ✔✔A man is at the clinic fora
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 take off his undergarments.
d. Defer measuring vital signs until the end of the examination, which allows him time to become
comfortable.
b) Wash hands before and after every physical patient encounter. - ✔✔When performing a
physical examination, safety 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. There is no need to wash one's hands after removing gloves, as long as the gloves are still
intact.
b. Wash hands before and after every physical patient encounter.
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