A client is admitted with pneumonia and has a recent history of methicillin-resistant Staphylococcus aureus (MRSA). The client is placed in isolation. While caring for the client, which item should the nurse place in a designated biohazard bag before it is removed from the room?

Sputum specimen.

Bed linens.

The nurse's stethoscope.

Paper mask and gown.

Answer and Explanation

The Correct Answer is D

Choice A Reason: This is incorrect because a sputum specimen should be placed in a sealed container and labeled with the client's name, date, and time before it is removed from the room. The container should be transported to the laboratory in a plastic bag.

Choice B Reason: This is incorrect because bed linens should be placed in a leak-proof laundry bag and handled with minimal agitation before they are removed from the room. The laundry bag should be closed securely and transported to the laundry facility.

Choice C Reason: This is incorrect because the nurse's stethoscope should be cleaned and disinfected with an alcohol wipe or a germicidal solution before it is removed from the room. The stethoscope should not be shared with other clients or staff.

Choice D Reason: This is correct because paper mask and gown are disposable items that are contaminated with the client's respiratory secretions and body fluids. They should be placed in a designated biohazard bag and disposed of properly before they are removed from the room.

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Correct Answer is A

Explanation

Choice A reason: This is the correct action to take when the nurse hears loud Korotkoff sounds immediately after releasing the air valve. This indicates that the cuff was not inflated high enough to occlude the arterial blood flow and the initial systolic reading was inaccurate. The nurse should release the air, wait for 15 to 30 seconds, and then reinflate the cuff to 30 mm Hg above the first systolic sound. This will ensure a more accurate measurement of the blood pressure.

Choice B reason: This is not the correct action to take when the nurse hears loud Korotkoff sounds immediately after releasing the air valve. Continuing the blood pressure assessment until the last Korotkoff sound is heard will result in a lower systolic reading and a higher diastolic reading than the actual blood pressure of the client. The nurse should release the air and reinflate the cuff to 30 mm Hg above the first systolic sound.

Choice C reason: This is not the correct action to take when the nurse hears loud Korotkoff sounds immediately after releasing the air valve. Repositioning the stethoscope in the antecubital fossa over the palpable brachial pulse point will not change the fact that the cuff was not inflated high enough to occlude the arterial blood flow. The nurse should release the air and reinflate the cuff to 30 mm Hg above the first systolic sound.

Choice D reason: This is not the correct action to take when the nurse hears loud Korotkoff sounds immediately after releasing the air valve. Inflating the cuff quickly to a higher mm Hg reading than the previously auscultated systolic sound will cause discomfort and pain to the client and may damage the blood vessels. The nurse should release the air and reinflate the cuff to 30 mm Hg above the first systolic sound.

A. Hematocrit. B. Neutrophil count. C. Serum potassium and sodium levels. D. Blood pH level.

Correct Answer is B

Explanation

Choice A Reason: This is incorrect because hematocrit is a measure of the percentage of red blood cells in the blood, which can indicate anemia or polycythemia, but not infection.

Choice B Reason: This is correct because neutrophil count is a measure of the number of neutrophils, which are white blood cells that fight infection and inflammation. A high neutrophil count can indicate a bacterial infection, such as in the wound.

Choice C Reason: This is incorrect because serum potassium and sodium levels are measures of the electrolyte balance in the blood, which can indicate dehydration, fluid overload, or kidney dysfunction, but not infection.

Choice D Reason: This is incorrect because blood pH level is a measure of the acidity or alkalinity of the blood, which can indicate acidosis or alkalosis, but not infection.

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A client is admitted with pneumonia and has a recent history of methicillin-resistant Staphylococcus aureus (MRSA). The client is placed in isolation. While caring for the client, which item should the nurse place in a designated biohazard bag before it is removed from the room?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While assessing a client’s blood pressure using an aneroid sphygmomanometer, the nurse inflates the cuff to an initial reading of 160 mm calibration. Upon release of the air valve, the nurse immediately hears loud Korotkoff sounds. Which action should the nurse implement next?

Correct Answer is A

Explanation

While changing the dressing of a client with a leg ulcer, the nurse observes a red, tender, and swollen wound at the site of the lesion. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

Correct Answer is B

Explanation

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