NR302 HEAD TO CHEST ASSESSMENT SCRIPT
COMPREHENSIVE STUDY GUIDE QUESTIONS AND
VERIFIED ANSWERS [GET IT RIGHT] NEWEST
EDITION 2024
The nurse is admitting a client with an infected left ear cyst. As part of the
admission, a head-to-chest assessment is indicated. Before examining the client,
it is important the nurse completes which nursing actions? Select all that apply.
Sanitize the stethoscope endpiece with an alcohol swab
Observe the client's face and body language for signs of pain or distress
Ask the client to empty their bladder
Organize supplies to avoid interruptions
Perform hand hygiene
A client-centered health assessment yields both subjective and objective data.
The nurse would ask questions to elicit _______ data and would auscultate heart
sounds to elicit ______ data.
Subjective
Objective
The nurse is inspecting the client's neck. Which three (3) health assessment
inspection steps will the nurse take during the neck examination?
Observe for symmetry and midline alignment of the trachea
Observe for masses on the neck
Observe for full range of motion of the neck
Based on the notes and orders received, the nurse prepares to complete a
cardiovascular exam on the client. Which of these components should be
included in the examination? Select all that apply.
Palpate pulses
Auscultate carotid arteries
In the table below, choose which supplies are indicated or not indicated for the
preparation for or performance of a head-to-chest assessment.
Indicated: Clean gloves
Tongue blades
Soap or alcohol-based hand rub
Stethoscope
Not Indicated: Sterile drape
Nurse is auscultating heart sounds and client increases television volume to the
max
Nurse asks client to lower television volume
Client breath sounds need to be auscultated and the client is in a supine position
Client needs to be sitting upright to assess thorax and lungs
Nurse is assessing the skin and finds a mole of irregular shape that client states
bleeds periodically
COMPREHENSIVE STUDY GUIDE QUESTIONS AND
VERIFIED ANSWERS [GET IT RIGHT] NEWEST
EDITION 2024
The nurse is admitting a client with an infected left ear cyst. As part of the
admission, a head-to-chest assessment is indicated. Before examining the client,
it is important the nurse completes which nursing actions? Select all that apply.
Sanitize the stethoscope endpiece with an alcohol swab
Observe the client's face and body language for signs of pain or distress
Ask the client to empty their bladder
Organize supplies to avoid interruptions
Perform hand hygiene
A client-centered health assessment yields both subjective and objective data.
The nurse would ask questions to elicit _______ data and would auscultate heart
sounds to elicit ______ data.
Subjective
Objective
The nurse is inspecting the client's neck. Which three (3) health assessment
inspection steps will the nurse take during the neck examination?
Observe for symmetry and midline alignment of the trachea
Observe for masses on the neck
Observe for full range of motion of the neck
Based on the notes and orders received, the nurse prepares to complete a
cardiovascular exam on the client. Which of these components should be
included in the examination? Select all that apply.
Palpate pulses
Auscultate carotid arteries
In the table below, choose which supplies are indicated or not indicated for the
preparation for or performance of a head-to-chest assessment.
Indicated: Clean gloves
Tongue blades
Soap or alcohol-based hand rub
Stethoscope
Not Indicated: Sterile drape
Nurse is auscultating heart sounds and client increases television volume to the
max
Nurse asks client to lower television volume
Client breath sounds need to be auscultated and the client is in a supine position
Client needs to be sitting upright to assess thorax and lungs
Nurse is assessing the skin and finds a mole of irregular shape that client states
bleeds periodically
