Which of the following should the nurse do before conducting a physical examination of a client? (Select all that apply)
Obtain and check needed equipment.
Turn on relaxing music of the client's choice.
Identify ways to ensure client privacy.
Wash hands.
Dim the lighting to promote comfort.
Correct Answer : A,C,D
Choice a reason:
Obtaining and checking the needed equipment is essential before conducting a physical examination. This ensures that all necessary tools are functional and readily available, which facilitates a smooth and efficient assessment process. It also minimizes interruptions that could cause discomfort or anxiety for the client.
Choice b reason:
While turning on relaxing music of the client's choice may create a calming environment, it is not a standard procedure before a physical examination. Music preferences are subjective, and what is relaxing for one person may be distracting for another. Additionally, music could interfere with the ability to hear heart, lung, or bowel sounds during auscultation.
Choice c reason:
Identifying ways to ensure client privacy is a fundamental nursing responsibility. It respects the client's dignity and promotes a sense of safety and comfort. Privacy can be ensured by closing curtains, securing the area, and making sure the examination is conducted in a private setting.
Choice d reason:
Washing hands is a critical step before any physical examination. It is a primary measure for infection control, protecting both the nurse and the client from potential transmission of microorganisms.
Choice e reason:
Dimming the lighting to promote comfort is not typically recommended before a physical examination. Adequate lighting is crucial for the inspection phase of the examination, allowing the nurse to observe the client's general appearance, skin color, and other physical characteristics accurately.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
This approach is recommended as it allows for a systematic comparison between the two sides of the chest. Percussion should start at the apices of the lungs, which are located just above the clavicles, and proceed downwards. This method ensures that any differences in percussion note, which could indicate underlying pathology, are identified by direct comparison.
Choice B Reason:
While this approach also involves a systematic assessment, it does not allow for immediate comparison between the two sides of the chest. It is important to compare corresponding areas on each side as you go to detect any asymmetry or changes in resonance.
Choice C Reason:
This method, similar to choice B, does not facilitate immediate side-to-side comparison during the assessment. Immediate comparison is crucial for identifying subtle differences that may indicate conditions such as pleural effusion or pneumothorax.
Choice D Reason:
Starting the percussion above the left clavicle and moving to the right chest after completing the left side does not allow for direct comparison of symmetrical chest areas. Additionally, assessing the right chest moving upward from the liver is not a standard practice, as the liver dullness can interfere with the percussion of the lower right lung fields.
Correct Answer is C
Explanation
Choice a reason:
Rhonchi are coarse, rattling respiratory sounds somewhat like snoring, usually caused by obstruction or secretion in the larger airways. They are not considered normal breath sounds and are typically heard in conditions such as chronic bronchitis.
Choice b reason:
Crackles are the sounds you will hear in a lung field that has fluid in the small airways. These sounds are commonly heard in patients with pneumonia, heart failure, and restrictive pulmonary diseases. They are not normal breath sounds.
Choice c reason:
Bronchovesicular sounds are normal breath sounds heard over the main bronchus area and over the upper right posterior lung field. They have a medium pitch and intensity and are heard on both inspiration and expiration. In a healthy individual, these sounds are expected to be heard in the 1st and 2nd intercostal spaces near the sternal body.
Choice d reason:
Tracheal breath sounds are harsh, high-pitched sounds heard when auscultating over the trachea in the neck. They are not normally heard over the intercostal spaces of the chest wall.
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