Nursing Health Assessment A Best Practice Approach 1st edition by Jensen -Test Bank
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1. |
What tool does the nurse use to auscultate the patient’s abdomen? |
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A) None B) Fetoscope C) Sonoscope D) Stethoscope |
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2. |
When caring for patients in any healthcare environment, what is the most important technique for preventing infection? |
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A) |
Sterile technique |
C) |
Hand hygiene |
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B) |
Standard precautions |
D) |
Use of gloves |
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3. |
What steps are involved in the patient-to-patient transmission of pathogens? (Select all that apply.) |
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A) |
The nurse uses an alcohol-based hand rub for hand hygiene |
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B) |
Organisms are transferred from the patient to the nurse’s hands |
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C) |
Organisms survive on the nurse’s hands for less than 1 minute |
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D) |
The nurse’s contaminated hands come into direct contact with another patient |
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E) |
Organisms are present in the patient’s immediate environment |
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4. |
According to the 2009 guidelines from the Centers for Disease Control and Prevention (CDC), why are nurses supposed to wear gloves? (Select all that apply.) |
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A) |
To help maintain a sterile environment |
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B) |
To reduce transient contamination of the hands |
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C) |
To reduce the risk of infecting personnel |
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D) |
To prevent the transmission of bacteria from nurses to patients |
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E) |
To reduce the number of bacteria in the health care environment |
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5. |
A nursing instructor is discussing techniques used in the inspection of a patient. What would the instructor list as necessary or important when inspecting a patient? |
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A) |
Adequate exposure |
C) |
Therapeutic touch |
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B) |
Dim lighting |
D) |
Therapeutic communication |
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6. |
The nurse is assessing a patient who is new to the unit. During an inspection of the patient, what will the nurse do? |
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A) |
Tell the patient that modesty is not necessary |
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B) |
Make sure that the patient is covered |
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C) |
Look for internal abnormalities |
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D) |
Smell for odors |
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7. |
A new graduate nurse is inspecting a patient. What is a challenge this nurse will face? |
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A) |
Maintaining patient modesty |
C) |
Identifying subtle differences |
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B) |
Learning how to perform an inspection |
D) |
Documenting what is normal |
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8. |
For what is light palpation appropriate? (Select all that apply.) |
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A) |
Inflamed areas of skin |
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B) |
Internal organs |
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C) |
Skin texture |
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D) |
Deep pain |
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E) |
Surface lesions |
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9. |
Nursing students are in the laboratory practicing palpation. What would they learn about the best depth for moderate palpation? |
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A) ½ to 1 cm B) 1 to 2 cm C) 1 to 2½ cm D) 2 to 3 cm |
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10. |
When percussing a patient, where would the nurse expect to find the loudest tones? |
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A) Over the liver B) Over the bladder C) Over the spleen D) Over the lungs |
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11. |
A patient presents at the clinic complaining of a possible sinus infection. How would the nurse assess the sinuses in this patient? |
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A) Indirect percussion B) Palpation C) Direct percussion D) Auscultation |
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12. |
A student nurse is spending clinical hours on the medical-surgical unit with an experienced nurse. The student is assessing a patient using indirect percussion. Does the student hear what sound while percussing the center of the patient’s abdomen? |
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A) Resonance B) Tympany C) Dullness D) Damping |
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13. |
When auscultating the patient’s lungs, how should the nurse position the earpieces of the stethoscope? |
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A) |
Pointed toward the nose |
C) |
At a 90° angle from the nose |
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B) |
Pointed toward the occiput |
D) |
At a 45° angle to the occiput |
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14. |
While beginning assessment of a patient’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? |
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A) |
The bell |
C) |
The earpieces |
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B) |
The small side of the chest piece |
D) |
The diaphragm |
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15. |
Student nurses are in the laboratory learning auscultation techniques. How would they learn to hold the chest piece on the patient? |
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A) |
Place the endpiece between the thumb and the index finger |
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B) |
Place the index and middle fingers on top of the stethoscope |
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C) |
Place the endpiece between the index and the middle fingers |
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D) |
Place the thumb and index finger on top of the stethoscope |
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16. |
When assessing a patient, the first skill used is inspection. What purpose does inspection serve? |
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A) |
Gathering information |
C) |
Observing modesty |
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B) |
Feeling abnormalities |
D) |
Identifying internal abnormalities |
