Nokea
You are preparing to perform an initial shift assessment. You know that the correct order in which you should perform the five techniques for objective assessment (except for the abdomen) is
- A. Auscultation, olfaction, observation, palpation, and percussion
- B. Observation, auscultation, palpation, percussion, and olfaction
- C. Observation, palpation, percussion, auscultation, and olfaction
- D. Olfaction, auscultation, observation, palpation, and percussion
- E. Olfaction, observation, auscultation, percussion, and palpation
Correct Answer: B
Rationale: The correct order for assessment (except abdomen) is observation, auscultation, palpation, percussion, and olfaction to avoid altering findings.
You may also like to solve these questions
You have just completed auscultation of the patient's lungs. The sounds that you heard were sort of rattling; however, they cleared when the patient coughed. What term accurately describes what you heard?
- A. Crackles
- B. Rhonchi
- C. Wheezes
- D. Pleural friction rub
- E. Stridor
Correct Answer: B
Rationale: Rhonchi are rattling sounds that often clear with coughing, indicating mucus in the larger airways.
Which lobe(s) of the lungs is(are) accessible for auscultation only posteriorly and laterally?
- A. The left upper lobe
- B. The left lower lobe
- C. The right upper lobe
- D. The right middle lobe
- E. The right lower lobe
Correct Answer: B,E
Rationale: The left and right lower lobes are accessible posteriorly and laterally due to their anatomical position.
You are caring for a patient with mitral valve stenosis. You plan to assess the mitral valve during your initial assessment. Where will you be best able to auscultate the mitral valve?
- A. The right base of the heart
- B. The left base of the heart
- C. The apex of the left ventricle
- D. The left lateral sternal border
Correct Answer: C
Rationale: The mitral valve is best heard at the apex of the left ventricle, typically in the 5th intercostal space, midclavicular line.
When you assessed the radial pulse and the apical pulse of one of your patients, you noted that one of the pulses was slower than the other one. Which one of the following describes the assessment finding that you obtained?
- A. The radial pulse was faster than the apical pulse
- B. The apical pulse was faster than the radial pulse
- C. The radial pulse was slower than the apical pulse
- D. The apical pulse was slower than the radial pulse
Correct Answer: C
Rationale: A pulse deficit occurs when the radial pulse is slower than the apical pulse due to weak or missed peripheral pulses.
Which of the following assessment findings is not within the textbook normal range?
- A. 23 bowel sounds per minute in each quadrant
- B. Capillary refill of 5 seconds in a 41-year-old male patient
- C. Respiratory rate of 24 per minute
- D. Systolic pressure of 86 mm Hg
- E. Diastolic pressure of 62 mm Hg
Correct Answer: B,D
Rationale: Capillary refill of 5 seconds (normal is <2-3 seconds) and systolic pressure of 86 mm Hg (normal is 90-120 mm Hg) are outside normal ranges.