The nurse is preparing to assess an adult client who presents to the emergency room 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 of the following should the nurse incorporate into the physical assessment of this client? Standard Text: Select all that apply. 1. Wash hands in the presence of the client.
2. Put on nonsterile gloves to examine the client.
3. Ensure that the client has an empty bladder before beginning the physical assessment.
4. Instruct the client to hold all questions and comments until the completion of the assessment so that the nurse can focus on the exam.
5. Assess only the left lower extremity since this is the injured body part.

Answer 1

1,2
Rationale 1: Wash hands in the presence of the client. The nurse should always perform handwashing prior to physical contact with a client.
Rationale 2: Put on nonsterile gloves to examine the client. Because this client has open wounds, the nurse should wear gloves during the physical assessment to protect against blood-borne pathogens.
Rationale 3: Ensure that the client has an empty bladder before beginning the physical assessment. 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.
Rationale 4: Instruct the client to hold all questions and comments until the completion of the assessment so that the nurse can focus on the exam. 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.
Rationale 5: Assess only the left lower extremity since this is the injured body part. The nurse should always do a comparison of both sides of the body.