Chapter 03: Assessment Techniques, Safety, and Infection Control

What tool does the nurse use to auscultate the client's abdomen?

D. Stethoscope

When caring for clients in any health care environment, what is the most important technique for preventing infection?

C. Hand hygiene

What steps are involved in the client-to-client transmission of pathogens? (Select all that apply.)

B. Organisms are transferred from the client to the nurse's hands

D. The nurse's contaminated hands come into direct contact with another client

E. Organisms are present in the client's immediate environment

According to the guidelines from the Centers for Disease Control and Prevention (CDC), why are nurses supposed to wear gloves? (Select all that apply.)

B. To help maintain a sterile environment

C. To reduce transient contamination of the hands

D. To reduce the risk of infecting healthcare personnel

A nursing instructor is discussing techniques used in the inspection of a client. What would the instructor note as a priority when inspecting a client?

A. Adequate exposure of the body par

The nurse is assessing a client who is new to the unit. During inspection of the client, what will the nurse do?

D. Smell for odors

A new graduate nurse is inspecting a client. What is a challenge the nurse will face?

C. Identifying subtle differences

For what is light palpation appropriate? (Select all that apply.)

A. Inflamed areas of skin

C. Skin texture

E. Surface lesions

Nursing students are in the laboratory practicing palpation. What would they learn about the best depth for moderate palpation?

B. 1 to 2 cm

When percussing a client, where would the nurse expect to find the loudest tones?

D. Over the lungs

A client presents at the clinic reporting a possible sinus infection. How would the nurse assess the sinuses in this client?

C. Direct percussion

A student nurse is spending clinical hours on the medical-surgical unit with an experienced nurse. The student is assessing a client using indirect percussion. The student hears what sound while percussing the center of the client's abdomen?

B. Tympany

When auscultating the client's lungs, how should the nurse position the earpieces of the stethoscope?

A. Pointed slightly forward toward the nose

While beginning the assessment of a client's abdomen, the nurse starts in the middle of the abdomen and expects to hear high-frequency sounds. What part of the stethoscope will provide the best sound with firm skin contact?

D. The diaphragm

Student nurses are in the laboratory learning auscultation techniques. How would they be instructed to hold the chestpiece on the client?

C. Place the endpiece between the index and the middle fingers

When assessing a client, the first skill used is inspection. What purpose does inspection serve?

A. Gathering information

The instructor asks the student why percussion is performed on a client. What would be the student's most accurate response?

C. To elicit tenderness

It is necessary for the nurse to accurately describe the sounds heard while percussing a client. Which of the following is a subjective description of percussion sound?

A. quality

A nurse who suffers from a respiratory infection is preparing to perform a shift assessment on a client when the urge to cough occurs. What is the nurse's best action?

A. Cough into the inner aspect of the elbow.

A nurse in the emergency department is assessing a client admitted with suspected appendicitis. The nurse would avoid using which kind of palpation over the right lower quadrant of this client?

C. Deep palpation