when performing a physical assessment what technique would the nurse always perform first
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NCLEX-RN

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1. When performing a physical assessment, what technique should the nurse always perform first?

Correct answer: B

Rationale: During a physical assessment, the nurse should always begin with inspection. The sequence of techniques for physical examination is inspection, palpation, percussion, and auscultation. These skills are performed in a specific order, except for the abdominal assessment where auscultation precedes palpation and percussion. Inspection allows the nurse to observe and gather initial information without direct contact. It is a crucial step that provides valuable insights before proceeding to palpation, percussion, and auscultation. Therefore, choice B, 'Inspection,' is the correct answer. Choices A, C, and D are incorrect because they should follow inspection in the sequence of a comprehensive physical assessment.

2. In which situation would the nurse use bimanual palpation technique?

Correct answer: B

Rationale: Bimanual palpation involves using both hands to envelop or capture specific body parts or organs like the kidneys, uterus, or adnexa. This technique is particularly useful for assessing the size, shape, consistency, and mobility of deep organs like the kidneys and uterus. Palpating the thorax of an infant (Choice A) is usually done with a different technique like gentle, single-handed palpation. Assessing pulsations and vibrations (Choice C) and assessing tenderness and pain (Choice D) typically do not require the use of bimanual palpation, making Choices A, C, and D incorrect.

3. Improper placement of the hands under the rib cage when performing the Heimlich maneuver could result in:

Correct answer: B

Rationale: The xiphoid process is a small, cartilaginous extension at the inferior end of the sternum. Placing the hands improperly during the Heimlich maneuver too close to this process can result in it breaking off and potentially causing damage to internal organs. Choices A and C are incorrect because the manubrium of the sternum and the coccyx are not in the area where the hands would typically be placed during the Heimlich maneuver.

4. Over a patient's lifespan, how does the pulse rate change?

Correct answer: A

Rationale: The correct answer is that the pulse rate starts out fast and decreases as the patient ages. In infants, the normal pulse rate is around 140 beats per minute, which then falls to an average of 80 beats per minute in adults. As individuals age, their pulse rate tends to decrease due to changes in cardiovascular function. Choice B is incorrect as the pulse rate typically decreases with age, rather than increases. Choice C is incorrect as there is a general trend of decreasing pulse rate as individuals age, rather than a continuous variation. Choice D is incorrect as the pulse rate does change over a patient's lifespan, starting fast in infants and decreasing as they age.

5. A 60-year-old patient has been treated for pneumonia for the past 6 weeks. The patient is seen today in the clinic for an unexplained weight loss of 10 pounds over the last 6 weeks. Which is an appropriate rationale for this patient's weight loss?

Correct answer: C

Rationale: Unexplained weight loss in a patient with pneumonia could indicate an underlying short-term illness or a chronic condition like endocrine disease, malignancy, depression, anorexia nervosa, or bulimia. Hypertension is not commonly associated with weight loss; it usually leads to weight gain due to fluid retention. Unhealthy eating habits are less likely to explain significant unexplained weight loss over a short period. Mental health dysfunctions can affect appetite but are not typically primary causes of significant unexplained weight loss.

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