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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 C

Explanation

A. Oatmeal is generally considered a good food for individuals with GERD as it can help absorb stomach acid.

B. Apples are typically a safe fruit for GERD sufferers.

C. Chocolate can relax the lower esophageal sphincter and may worsen GERD symptoms, so it should be avoided.

D. Nonfat milk is usually tolerated better than full-fat dairy products and may help soothe the stomach.

A. PICC line insertion site B. Breath sounds C. Temperature D. Heart rate

Correct Answer is ["A","C","D"]

Explanation

A. PICC line insertion site: The client reports pain, redness, and edema at the PICC line insertion site, which are signs of a possible infection. This finding requires immediate follow-up to prevent complications like bloodstream infection or sepsis.

B. Breath sounds: The client’s breath sounds are clear and unchanged from Day 1, so this finding does not require immediate follow-up.

C. Temperature: The client's temperature has risen to 39 °C (102.2 °F) from 37.2 °C (99 °F) on Day 1. Such a significant increase in temperature indicates a possible infection and needs prompt intervention.

D. Heart rate: The client’s heart rate has increased to 108/min from 66/min, suggesting tachycardia. This could be a response to infection, potentially linked to sepsis, and warrants immediate follow-up.

E. Albumin level: The albumin level has increased to within the normal range, which is a positive trend and does not require urgent intervention.

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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

A nurse is providing teaching for a client who has a new diagnosis of gastroesophageal reflux disease (GERD). The client asks about foods that should be avoided. Which food should the nurse encourage the client to avoid?

Correct Answer is C

Explanation

Select the 3 findings on day 3 that require immediate follow-up. Exhibits

Correct Answer is ["A","C","D"]

Explanation

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