TTT Exam 1 Chapter 3: Collecting
Objective Data: The Physical
Examination - ML8
The nurse is conducting a physical examination of a client who is in the lying
position. Place in order the areas the nurse will assess when completing this
examination.
a. Shins and ankles
b. Groin, hips, and knees
c. Breasts
✅✅
d. Chest and thorax
e. Cardiovascular - -c, d, e, b, a
✅✅
Which is the priority for the nurse conducting a physical examination of a client with
generalized muscle weakness? - -Limit position changes as much as possible
✅✅
What would be the expected tone elicited by percussion of a normal lung? -
-Resonance
✅✅
During the physical examination of your client you auscultate the sound of the client's
breathing. What area of the client are you assessing? - -Lungs
A client with scabies visits the health care facility for a follow-up appointment. Which
✅✅
preparation by the nurse is of greatest priority for the physical examination of this
client? - -Adequate lighting
A nurse will be performing a complete physical examination of a man who has
emphysema with a chronic productive cough, including an assessment of his oral
✅✅
cavity. Which pieces of personal protective equipment should the nurse wear? -
-Gloves, mask, protective eye goggles, gown
✅✅-inflamed areas of skin
Light palpation is most appropriate to assess the -
Which describes the nurse using the technique of percussion? - ✅✅-The nurse
notes resonance over the individual's thorax.
✅✅
During a comprehensive assessment, the primary technique used by the nurse
throughout the examination is - -inspection
✅✅
When assessing pulses, the nurse would use which part of the hand for palpation? -
-Finger pads
, While the nurse is preparing to begin a physical examination of a client, the nurse
notes that the bed is in the lowest position, the client is in a side-lying position, the
✅✅
television is on at a loud volume, and the lights are dimmed. How should the nurse
proceed with the assessment? Select all that apply. - -Adjust the bed to a
comfortable height.
Ask the client to reposition for the exam as necessary.
Lower the bed when the exam is completed.
✅✅
Which action by a nurse demonstrates the correct application of the principles of
standard precautions? - -Wearing gloves when palpating the tongue, lips, &
gums
The nurse is conducting a physical examination of a client. After completing the
✅✅
examination, the nurse realizes that part of the examination was omitted by mistake.
How should the nurse proceed? - -Complete the forgotten portion of the exam
out of sequence.
✅✅
What auscultation sound would the nurse expect when listening to heart sounds? -
-Rhythmic lub-dub
✅✅
A nurse is palpating a child's forehead for signs of fever. Which part of the hand
should the nurse use? - -Dorsal surface
A nurse in the community is completing manual blood pressure assessments at a
✅✅
recreation center. Which action should the nurse take to ensure the assessment is
accurate? - -Turn down the volume if the television or radio is on.
✅✅
The nurse understands that the preferred method of hand hygiene when hands are
not visibly soiled is what? - -Alcohol-based rub
✅✅
The nurse is caring for the client who is receiving heparin. The nurse plans to: -
-Wear clean gloves when administering heparin to the client
How should the nurse place the ear of an adult when using the otoscope? - ✅✅-Up
and back
✅✅
Universal precautions are primarily designed to protect the health care worker from
what? - -Blood-borne pathogens
During a comprehensive assessment of the lungs of an adult client with a diagnosis
✅✅
of emphysema, the nurse anticipates that during percussion the client will exhibit -
-hyperresonance.
Objective Data: The Physical
Examination - ML8
The nurse is conducting a physical examination of a client who is in the lying
position. Place in order the areas the nurse will assess when completing this
examination.
a. Shins and ankles
b. Groin, hips, and knees
c. Breasts
✅✅
d. Chest and thorax
e. Cardiovascular - -c, d, e, b, a
✅✅
Which is the priority for the nurse conducting a physical examination of a client with
generalized muscle weakness? - -Limit position changes as much as possible
✅✅
What would be the expected tone elicited by percussion of a normal lung? -
-Resonance
✅✅
During the physical examination of your client you auscultate the sound of the client's
breathing. What area of the client are you assessing? - -Lungs
A client with scabies visits the health care facility for a follow-up appointment. Which
✅✅
preparation by the nurse is of greatest priority for the physical examination of this
client? - -Adequate lighting
A nurse will be performing a complete physical examination of a man who has
emphysema with a chronic productive cough, including an assessment of his oral
✅✅
cavity. Which pieces of personal protective equipment should the nurse wear? -
-Gloves, mask, protective eye goggles, gown
✅✅-inflamed areas of skin
Light palpation is most appropriate to assess the -
Which describes the nurse using the technique of percussion? - ✅✅-The nurse
notes resonance over the individual's thorax.
✅✅
During a comprehensive assessment, the primary technique used by the nurse
throughout the examination is - -inspection
✅✅
When assessing pulses, the nurse would use which part of the hand for palpation? -
-Finger pads
, While the nurse is preparing to begin a physical examination of a client, the nurse
notes that the bed is in the lowest position, the client is in a side-lying position, the
✅✅
television is on at a loud volume, and the lights are dimmed. How should the nurse
proceed with the assessment? Select all that apply. - -Adjust the bed to a
comfortable height.
Ask the client to reposition for the exam as necessary.
Lower the bed when the exam is completed.
✅✅
Which action by a nurse demonstrates the correct application of the principles of
standard precautions? - -Wearing gloves when palpating the tongue, lips, &
gums
The nurse is conducting a physical examination of a client. After completing the
✅✅
examination, the nurse realizes that part of the examination was omitted by mistake.
How should the nurse proceed? - -Complete the forgotten portion of the exam
out of sequence.
✅✅
What auscultation sound would the nurse expect when listening to heart sounds? -
-Rhythmic lub-dub
✅✅
A nurse is palpating a child's forehead for signs of fever. Which part of the hand
should the nurse use? - -Dorsal surface
A nurse in the community is completing manual blood pressure assessments at a
✅✅
recreation center. Which action should the nurse take to ensure the assessment is
accurate? - -Turn down the volume if the television or radio is on.
✅✅
The nurse understands that the preferred method of hand hygiene when hands are
not visibly soiled is what? - -Alcohol-based rub
✅✅
The nurse is caring for the client who is receiving heparin. The nurse plans to: -
-Wear clean gloves when administering heparin to the client
How should the nurse place the ear of an adult when using the otoscope? - ✅✅-Up
and back
✅✅
Universal precautions are primarily designed to protect the health care worker from
what? - -Blood-borne pathogens
During a comprehensive assessment of the lungs of an adult client with a diagnosis
✅✅
of emphysema, the nurse anticipates that during percussion the client will exhibit -
-hyperresonance.
