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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 B

Explanation

A. Assessing the pedal pulses does not provide relevant information about the irregularity of the radial pulse.

B. Assessing the apical pulse for a full minute is appropriate in this situation, as it provides a more accurate measurement of the heart rate and rhythm, especially when the radial pulse is irregular.

C. Assessing the popliteal pulses with a Doppler device is not necessary and does not directly address the irregular radial pulse.

D. While a pulse oximeter can provide information about oxygen saturation, it does not assess heart rate or rhythm.

A. Metabolic alkalosis B. Metabolic acidosis C. Respiratory alkalosis D. Respiratory acidosis E. Metabolic acidosis

Correct Answer is C

Explanation

A. Metabolic alkalosis is characterized by a high pH and a high HCO3- level; this does not match the provided values.

B. Metabolic acidosis would show a low pH and a low HCO3-, which does not match the findings.

C. The pH is high (7.45) while the Paco2 is low (30 mm Hg), indicating respiratory alkalosis. The low HCO3- could be a compensatory mechanism but does not change the primary interpretation of respiratory alkalosis.

D. Respiratory acidosis would be indicated by a low pH and a high Paco2, which is not the case here.

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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 assessing a client's radial pulse and determines that the pulse is irregular. Which action should the nurse take?

Correct Answer is B

Explanation

The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, [normal range: 7.35-7.45] Paco2 of 30 mm Hg (30 mmol/L), [normal range: 35-45] HCO3- of 20 mEq/L (20 mmol/L), [normal range: 22-26] Which condition would the nurse analyze these results to indicate?

Correct Answer is C

Explanation

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