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
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. Metabolic alkalosis is characterized by a high pH and elevated bicarbonate levels, which is not present in these results.
B. Respiratory alkalosis would present with an increased pH and decreased PaCO2, which does not apply here.
C. The low pH (7.12) indicates acidemia, and the elevated PaCO2 (90 mm Hg) suggests hypoventilation and respiratory acidosis due to CO2 retention. The bicarbonate level is within normal limits, further supporting respiratory acidosis.
D. Metabolic acidosis would be indicated by a low pH and low bicarbonate levels; however, the bicarbonate is normal in this case, ruling out metabolic acidosis.
Correct Answer is B
Explanation
A. Auscultating the area may not provide information about the dorsalis pedis pulse, which is a palpated pulse.
B. Using Doppler ultrasonography is the most appropriate next step to locate the dorsalis pedis pulse if it cannot be palpated, as it provides a non-invasive way to detect blood flow.
C. While documenting the absence of the pulse is necessary, it should be done after attempts to locate the pulse have been made.
D. It is not immediately necessary to ask a provider to assess the pulse; the nurse can use Doppler ultrasonography first to gather more information.