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The nurse is preparing to physically exam a client. What action by the nurse is most to take prior to beginning the client examination?

Wash hands prior to examination in the examination room.

Approach the client from the left side of the examination table.

Recap used needles and place them in the sharps container.

Remove gloves only after the examination is over.

Answer and Explanation

The Correct Answer is A

A. Hand hygiene is the most important action to prevent the spread of infection before any physical examination.

B. Approaching from the left side is unnecessary unless required by specific patient needs.

C. Needles should never be recapped as this increases the risk of needlestick injuries.

D. Gloves should be worn when appropriate but should not be the first action before an examination. Hand hygiene is essential before touching the client or any instruments.

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Correct Answer is A

Explanation

A. The patient is the primary source of information regarding their pain tolerance, as pain is subjective and only the patient can accurately describe their experience.

B. A patient's roommate cannot reliably report on the patient's pain experience.

C. The CNA may observe signs of pain but cannot determine the patient's subjective pain tolerance.

D. The nurse can assess the patient's pain based on behaviors and reports but relies on the patient for direct information.

A. Document the findings as a vernix caseosa and is consider it normal. B. Report the parents to the department of children and families. C. Educate the parents that the findings are normal and should fade away by the age of three. D. Notify the healthcare provider.

Correct Answer is C

Explanation

A. Documenting the findings is also important, but it should be noted as Mongolian blue spots rather than vernix caseosa.
B. Reporting the parents to the department of children and families would be inappropriate, as Mongolian blue spots are not a sign of abuse or neglect
C. Mongolian blue spots, also known as congenital dermal melanocytosis, are benign skin markings that are usually present at birth or appear shortly after. They are more common in individuals with darker skin tones and are not indicative of any disease or disorder.
D. While it is always prudent to notify the healthcare provider of any findings, in the case of Mongolian blue spots, no immediate medical intervention is necessary.

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The nurse is preparing to physically exam a client. What action by the nurse is most to take prior to beginning the client examination?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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