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The nurse in the clinic is preparing to perform a physical assessment on a client who arrived for a routine check-up. Before beginning the assessment, which four activities should the nurse carry out? (Select all that apply.)

Wash hands

Provide patient privacy

Obtain a provider healthcare order

Position the client comfortably on the sturdy examination table

Explain the procedure to the client

Answer and Explanation

Correct Answer : A,B,D,E

A. Washing hands is a crucial step to prevent infection and maintain hygiene before any physical assessment.

B. Providing patient privacy is essential to ensure the client's comfort and confidentiality during the assessment.

C. While it’s important to follow the provider’s orders, a routine check-up typically does not require a new healthcare order, as the nurse can perform the assessment as part of standard care.

D. Positioning the client comfortably on the examination table is necessary to facilitate the assessment and ensure the client's comfort during the procedure.

E. Explaining the procedure to the client helps to alleviate anxiety, improve understanding, and foster cooperation during the assessment.

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Correct Answer is A

Explanation

A. The bell of the stethoscope is best used to listen for low-pitched sounds, including some types of murmurs, and can help assess the quality and intensity of a cardiac murmur.

B. While palpation can provide some information about the heart's function (such as thrills), it is not the primary method for assessing the quality of a murmur.

C. A Doppler ultrasound device is used for measuring blood flow and can help in assessing murmurs but does not provide the quality assessment needed for characterizing a murmur.

D. Percussion is not typically used to evaluate murmurs; it is more useful for assessing the size and borders of organs.

A. The client is restless. B. The client's pupils are dilated. C. The client reports a burning sensation. D. The client is grimacing

Correct Answer is C

Explanation

A. Restlessness is an objective sign that may indicate pain, but it is not a subjective report from the client.

B. Pupil dilation is an objective physiological response often associated with pain or stress, not a subjective indicator.

C. A report of a burning sensation is a subjective indicator because it is based on the client’s own description of their pain experience.

D. Grimacing is an objective observation by the nurse, not a subjective report from the client.

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The nurse in the clinic is preparing to perform a physical assessment on a client who arrived for a routine check-up. Before beginning the assessment, which four activities should the nurse carry out? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

To determine the quality and intensity of a cardiac murmur, the nurse would take which action?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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