The nurse is preparing to perform a complete health assessment on a client. Which of the following activities should the nurse perform just prior to this examination? Standard Text: Select all that apply
1. Put on nonsterile gloves.
2. Provide an opportunity for the client to void.
3. Wash hands in the presence of the client.
4. Turn on soft music to relax the client.
5. Lower the lights in the room to prevent glare.
2,3
Rationale 1: Put on nonsterile gloves. Gloves are needed only if the nurse may come into contact with the client's blood or body fluids, such as during the assessment of the genitalia or anus.
Rationale 2: Provide an opportunity for the client to void. The client should be given an opportunity to void prior to physical assessment. This helps the client feel more comfortable and facilitates the assessment of the abdomen and reproductive organs.
Rationale 3: Wash hands in the presence of the client. The nurse should always perform handwashing in the presence of the client prior to physical contact. This demonstrates that the nurse is providing for the client's safety and also protects the nurse.
Rationale 4: Turn on soft music to relax the client. The assessment should take place in a quiet environment in order for the nurse to correctly identify sounds and their characteristics.
Rationale 5: Lower the lights in the room to prevent glare. The room should be brightly lit to facilitate good visibility.
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