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The nurse is performing a thoracic Barrel chest
assessment on a client with chronic
asthma and hyperinflation of the
lungs. Which finding should be
expected for this client?
The nurse is assessing bowel sounds Note the character and frequency of bowel sounds
for a hospitalized client. The nurse
has heard bowel sounds in the right
upper quadrant. What action should
the nurse take next?
During inspection of a client's mouth Document an intact gag reflex.
and pharynx, the nurse places a
tongue blade on the back of the
tongue which causes the client to
gag. After removing the tongue
blade, what action should the nurse
take?
,When teaching a client how to Upper outer quadrant.
perform a monthly breast self-
assessment, the nurse should tell the
client that it is most important to
assess which part of the breast more
closely for changes?
The nurse is assessing a A waist circumference is greater than 35 inches in
postmenopausal client who has a women puts you at higher risk for type 2 diabetes
BMI of 32. The client has a chest and heart disease."
measurement of 42 inches, waist
measurement of 45 inches, and hip
measurement of 50 inches. What
important message should the nurse
explain to the client to promote
health promotion?
The nurse performs a physical Height reduction of 1.5 inches.
assessment on an older female
client. Which change from the prior
exam may be an indication of
osteoporosis?
While conducting an interview to Sit quietly to allow the client to respond
obtain a health history, the nurse comfortably.
notices that the client pauses
frequently and looks at the nurse
expectantly. Which response is best
for the nurse to provide?
A client is in the clinical for a yearly Ask the client to urinate before beginning the
physical examination. Which action examination.
should the nurse take when
preparing to examine the client's
abdomen?
, Which respiratory condition should Bradypnea.
the nurse document after measuring
a respiratory rate of 8
breaths/minute?
Which procedure should the nurse Measure the apical pulse and compare it to the
use to assessfor a pulse deficit? peripheral pulse.
*A pulse deficit is a palpable difference between
the apical pulse at the point of maximal impulse
and the radial pulse palpated at the wrist.
A client has been diagnosed with Dull, thud-like.
bilateral lower lobe atelectasis. What
percussion sound should the nurse
expect to hear when percussing over
the client's lower lobes?
A client is being assessed upon Inspect the hair and skin.
admission to the medical-surgical
unit. The nurse is preparing to
complete a head-to-toe assessment
and will begin at the head of the
client. Which technique should the
nurse use to begin the assessment?
The nurse is assessing a healthy Deep palpation above and to the left of the
young adult during an annual umbilicus.
physical examination. Which
assessment technique should the
nurse implement when palpating the
abdominal aorta?