The nurse is preparing to assess an adult client who presents to the emergency department (ED) after falling down some steps at home. The client complains of left ankle pain and has open abrasions to the left knee and shin

Question

Which should the nurse incorporate into the physical assessment of this client?
Select all that apply.
1. Washing hands in the presence of the client.
2. Putting on nonsterile gloves to examine the client.
3. Ensuring that the client has an empty bladder before beginning the physical assessment.
4. Instructing the client to hold all questions and comments until the completion of the assessment so that the nurse can focus on the exam.
5. Assessing only the left lower extremity since this is the injured body part.

Answer 1

Correct Answer: 1, 2

The nurse should always perform handwashing prior to physical contact with a client. Because this client has open wounds, the nurse should wear gloves during the physical assessment to protect against blood-borne pathogens. When the client's abdomen will be examined, it is important to have the client empty the bladder to promote client comfort and facilitate the examination. It is not a priority in this situation. The nurse should encourage the client to ask questions and offer comments during assessment. This helps the nurse gain accurate information and helps to relieve a client's anxiety. The nurse should always do a comparison of both sides of the body.