During auscultation of a patient's heart sounds, the nurse hears an unfamiliar sound. The nurse should:
a. Document the findings in the patient's record.
b. Wait 10 minutes, and auscultate the sound again.
c. Ask the patient how he or she is feeling.
d. Ask another nurse to double check the finding.
Question 2The nurse is preparing to examine a 6-year-old child. Which action is most appropriate?
a. The thorax, abdomen, and genitalia are examined before the head.
b. Talking about the equipment being used is avoided because doing so may increase the child's anxiety.
c. The nurse should keep in mind that a child at this age will have a sense of modesty.
d. The child is asked to undress from the waist up.
Question 3When examining an infant, the nurse should examine which area first?
a. Ear
b. Nose
c. Throat
d. Abdomen
Question 4The nurse is preparing to assess a hospitalized patient who is experiencing significant shortness of breath. How should the nurse proceed with the assessment?
a. The patient should lie down to obtain an accurate cardiac, respiratory, and abdominal assessment.
b. A thorough history and physical assessment information should be obtained from the patient's family member.
c. A complete history and physical assessment should be immediately performed to obtain baseline information.
d. Body areas appropriate to the problem should be examined and then the assessment completed after the problem has resolved.
Question 5Which of these statements is true regarding the use of Standard Precautions in the health care setting?
a. Standard Precautions apply to all body fluids, including sweat.
b. Use alcohol-based hand rub if hands are visibly dirty.
c. Standard Precautions are intended for use with all patients, regardless of their risk or presumed infection status.
d. Standard Precautions are to be used only when nonintact skin, excretions containing visible blood, or expected contact with mucous membranes is present.
Question 6The most important step that the nurse can take to prevent the transmission of microorganisms in the hospital setting is to:
a. Wear protective eye wear at all times.
b. Wear gloves during any and all contact with patients.
c. Wash hands before and after contact with each patient.
d. Clean the stethoscope with an alcohol swab between patients.
Question 7When examining an older adult, the nurse should use which technique?
a. Avoid touching the patient too much.
b. Attempt to perform the entire physical examination during one visit.
c. Speak loudly and slowly because most aging adults have hearing deficits.
d. Arrange the sequence of the examination to allow as few position changes as possible.
Question 8When examining a 16-year-old male teenager, the nurse should:
a. Discuss health teaching with the parent because the teen is unlikely to be interested in promoting wellness.
b. Ask his parent to stay in the room during the history and physical examination to answer any questions and to alleviate his anxiety.
c. Talk to him the same manner as one would talk to a younger child because a teen's level of understanding may not match his or her speech.
d. Provide feedback that his body is developing normally, and discuss the wide variation among teenagers on the rate of growth and development.
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