The nurse is about to perform a physical assessment on an adult client. Before beginning this phase of the client's health assessment, the nurse should first:
1. Provide a gown for the client to change into.
2. Explain to the client what will happen during the examination.
3. Obtain a written consent.
4. Wash hands in the presence of the client.
2
Rationale 1: The client may need to change into a gown in order for the nurse to perform the assessment; however, the nurse should first explain what will be happening before asking the client to change clothing.
Rationale 2: The first thing the nurse should do prior to beginning the physical assessment of a client is explain to the client what is about to happen. This helps to relieve a client's anxiety and enlists the client's cooperation with the assessment.
Rationale 3: Obtaining a written consent is not necessary, unless an invasive procedure will be performed.
Rationale 4: Handwashing should be performed just before the nurse begins to touch the client and after a full explanation of the process is given and again at the completion of the physical assessment.
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