The nurse is examining a client's lower leg and notices a draining ulcer. Which of the following should be the appropriate action by the nurse?

Continue to examine the ulceration and then wash hands

Wash hands and then contact the physician

Wash hands, put on gloves, and then continue with the examination of the ulceration

Wash hands, proceed with the rest of the physical examination, and perform the examination of the leg ulceration last

Answer and Explanation

The Correct Answer is C

A. Continue to examine the ulceration and then wash hands. This action does not prioritize infection control. It is important to wash hands and put on gloves before touching the ulcer to prevent contamination and the spread of infection.

B. Wash hands and then contact the physician. While washing hands is important, contacting the physician before fully assessing the ulceration is not the most appropriate immediate action. The nurse should first complete the assessment while following proper infection control protocols.

C. Wash hands, put on gloves, and then continue with the examination of the ulceration. This is the appropriate action. Washing hands and putting on gloves before examining the ulcer ensures proper infection control and allows the nurse to assess the ulcer safely and thoroughly.

D. Wash hands, proceed with the rest of the physical examination, and perform the examination of the leg ulceration last. This approach delays the assessment of the ulceration, which is not ideal. The ulcer should be examined as soon as the nurse is aware of it, following appropriate infection control practices.

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Free Nursing Study Resources

Correct Answer is A

No explanation

A. Using strong pressure, palpate with both hands to compare the two sides B. Gently pinch each node between one's thumb and forefinger, and then move down the neck muscle C. Using the index finger, firmly palpate by applying pressure in a rotating pattern D. Using gentle pressure, palpate with both hands to compare the two sides

Correct Answer is D

Explanation

A. Using strong pressure, palpate with both hands to compare the two sides.Strong pressure is not recommended when palpating lymph nodes, as it could cause discomfort and may not provide accurate information. Lymph nodes are best assessed using gentle pressure.

B. Gently pinch each node between one's thumb and forefinger, and then move down the neck muscle.Pinching the lymph nodes is not the correct technique. Lymph nodes should be palpated gently, not pinched, to assess their size, consistency, and mobility.

C. Using the index finger, firmly palpate by applying pressure in a rotating pattern.While a rotating pattern is part of the technique, using firm pressure with a single finger is not ideal. Gentle pressure and the use of multiple fingers or both hands are preferred for more accurate assessment.

D. Using gentle pressure, palpate with both hands to compare the two sides.This is the correct technique. Gentle pressure should be used to palpate the lymph nodes with both hands, allowing for comparison between the two sides. This method helps the nurse accurately assess the size, consistency, mobility, and tenderness of the lymph nodes.

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The nurse is examining a client's lower leg and notices a draining ulcer. Which of the following should be the appropriate action by the nurse?

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