NEW
Font size
WorksheetsHA_Post Assessment
Total questions: 10
Worksheet time: 10mins
In assessing the lateral deviation of the spine by asking client to stand then bend forward at the waist. What is the position of the nurse when assessing?
The nurse is standing behind the client
The nurse is sitting behind the client
The nurse is standing beside the client
The nurse is sitting behind the client
What is the nursing consideration when palpating a client who have respiratory complaints?
Avoid deep palpation for painful areas, especially if fractured rib is suspected.
Skip palpating the painful areas
Skip palpating those areas with abnormal movements
Only palpate chest areas with bulges
When palpating the chest form vocal fremitus what should the nurse instruct to the patient?
Ask the patient to cough
Ask the patient to repeat words like “ blue moon, or stress stress”
Ask the patient to take a deep breath
Ask the patient to bend head & fold arms forward across chest
In percussing the ICS using a pattern in the posterior thorax, what is the nurse expect as normal sound in thin patients and those with decreased musculature?
Resonant Sound
Hyperresonant Sound
Tympany
Dullness
The nurse is assessing the anterior thorax of the patient, the nurse heard the loudest fremitus in which part of the patient?
apex
upper rib
base of the lungs
scapula
When auscultating for the breath sounds the nurse must
Listen to at least one full respiration in each location
Always ask the patient to take slow, deep breaths.
Listen when the patient inhales and then going to the next site during exhalation
Ask the patient to remove his/her entire clothing
A nurse auscultates a client's lungs and hears fine crackles. What is an appropriate action by the nurse?
Instruct the client to cough forcefully
Listen again with the bell of the stethoscope
Have the client breathe through the mouth
Assess for the use of accessory muscles
What is/are the normal finding of Posterior Thorax?
A small protrusion noted at same location
Temperature warm to touch and equal bilaterally
Perspiration noted and equal tactile fremitus
Skin is intact and with uniform temperature
When auscultating the lungs, it is important to:
Compare each side bilaterally
Note abnormal sounds
Ask the patient to take slow, deep breaths
All of the above.
Which action by a nurse demonstrates proper technique for assessment of chest expansion?
Beginning at the scapular line, percuss the intercostal spaces along both sides of the posterior chest
Place both hands on the posterior chest at T9, press thumbs together, and then ask client to take a deep breath
Place the stethoscope on the posterior chest wall, ask the client to take a deep breath, and observe chest rise and fall
Use the ball of both hands to feel for vibrations in a symmetrical pattern across the posterior chest
