The nurse is preparing to conduct a physical assessment. Which statement indicates a correct action by the nurse?

Examine tender or painful areas first to help relieve the patient's anxiety.

Organize the assessment to ensure that the patient does not change positions too often.

Perform all examinations from the left side of the bed.

Follow the same examination sequence, regardless of the patient's age or condition.

Answer and Explanation

The Correct Answer is B

Rationale:

A. Examining tender or painful areas first is not recommended. Starting with areas that cause discomfort may increase the patient’s anxiety and limit cooperation during the rest of the assessment. It is generally best to begin with non-tender areas and save painful areas for last.

B. Organizing the assessment to minimize position changes is correct. Efficient sequencing reduces patient fatigue, discomfort, and unnecessary movement, which is especially important for clients who are weak, ill, or have mobility limitations. This demonstrates proper planning and patient-centered care.

C. Performing all examinations from the left side of the bed is incorrect. While some assessments are routinely done from the left side (e.g., cardiac examination), not all examinations require this position. The nurse should adjust based on the system being assessed and the patient’s condition.

D. Following the same examination sequence regardless of age or condition is inappropriate. Assessment techniques should be adapted based on the client’s age, health status, and ability to cooperate. A rigid sequence may not address specific needs or accommodate safety considerations.

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Correct Answer is C

Explanation

Rationale:

A. A deep tissue pressure injury involves intact or non-intact skin with a localized area of persistent non-blanchable deep red, maroon, or purple discoloration, often resulting from underlying soft tissue damage. In this case, the redness is superficial, localized, and the skin is intact, so it does not meet the criteria for a deep tissue injury.

B. A skin tear is a traumatic wound caused by friction or shear, resulting in partial or full separation of the skin layers. This client’s skin is intact with redness and no tearing, so it is not a skin tear.

C. Stage 1 pressure injury is characterized by intact skin with non-blanchable redness over a bony prominence. This aligns exactly with the nurse’s observation: the sacral skin is intact, and redness does not blanch when pressure is applied. Stage 1 is considered the earliest recognizable stage of pressure injury and requires preventive interventions to avoid progression.

D. Stage 2 pressure injury involves partial-thickness skin loss with exposed dermis, which may appear as a shallow open ulcer or blister. Since this client’s skin remains intact, the finding does not meet the criteria for stage 2.

A. Using a Doppler ultrasound device over the brachial artery. B. Palpating the radial artery while counting beats for 30 seconds. C. Using a stethoscope, auscultate at the second intercostal space, right midclavicular line. D. Using a stethoscope, auscultate at the fifth intercostal space, left midclavicular line.

Correct Answer is D

Explanation

Rationale:

A. Doppler devices are useful for detecting weak pulses, especially in peripheral arteries, but the brachial artery does not provide a direct assessment of the apical heart rate, which reflects actual cardiac contractions at the apex of the heart.

B. Radial pulse measurement can underestimate or miss irregularities such as arrhythmias because it only reflects the peripheral pulse, which may differ from actual cardiac contractions (pulse deficit). Counting for only 30 seconds can also reduce accuracy, particularly in irregular rhythms.

C. The second intercostal space at the right sternal border is the aortic valve auscultation site, not the apex of the heart. This site is used to assess heart sounds like the aortic valve closure, not to measure apical pulse rate.

D. The apical pulse is most accurately measured at the apex of the heart, which is located at the fifth intercostal space at the left midclavicular line. Auscultation here allows direct assessment of ventricular contractions, making it the gold standard for measuring heart rate and rhythm, especially in patients with irregular rhythms or when accurate measurement is critical.

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The nurse is preparing to conduct a physical assessment. Which statement indicates a correct action by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing the sacral area of a client who has been on bed rest for several days. The nurse notes intact skin with localized redness that does not blanch when pressure is applied. How should the nurse document this finding?"

Correct Answer is C

Explanation

When assessing the apical pulse, which of the following techniques is most accurate for obtaining the pulse rate?

Correct Answer is D

Explanation

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