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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 ["3.6"]

Explanation

Step 1: Calculate the total daily dose of digoxin:

12 mcg/kg/day * 30 kg = 360 mcg/day

Step 2: Calculate the dose per administration:

Since the dose is to be divided equally every 12 hours, each dose will be half of the total daily dose:

360 mcg/day / 2 = 180 mcg/dose

Step 3: Convert mcg to mg:

180 mcg = 0.18 mg

Step 4: Calculate the volume to administer:

We know that 0.05 mg of digoxin is contained in 1 mL of the elixir. So, to find the volume for 0.18 mg, we can set up a proportion:

0.05 mg / 1 mL = 0.18 mg / x mL

Cross-multiplying:

0.05x = 0.18

Solving for x:

x = 0.18 / 0.05 = 3.6 mL

A. Temperature B. Respirations C. Blood pressure D. Heart rate

Correct Answer is D

Explanation

A. The tympanic temperature of 37.1° C (98.8° F) is within normal limits and does not require re-measurement.

B. The respiratory rate of 14/min is also within the normal range (12-20 breaths per minute).

C. The blood pressure of 98/77 mm Hg is not alarmingly low and does not require immediate re-measurement.

D. A pulse rate of 42/min indicates bradycardia (normal resting heart rate is typically between 60-100 bpm), so it is important to re-measure to confirm this finding and assess the client's cardiovascular status.

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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

Correct Answer is ["3.6"]

Explanation

An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1° C (98.8° F), pulse 42/min, respiratory rate 14/min, and BP 98/77 mm Hg. Which vital sign should the nurse re-measure?

Correct Answer is D

Explanation

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