A nurse is admitting a client who requires droplet precautions due to influenza. Which of the following actions should the nurse take?

Place the client in a room with negative airflow.

Wear a gown when providing care to the client.

Ensure the client's room has HEPA filtration.

Wear a mask when providing care to the client.

Answer and Explanation

The Correct Answer is D

A. Inspection is usually done first to observe any obvious abnormalities, but it is not the immediate action when the client reports pain.

B. Palpation should be done last, as it can cause discomfort or alter the findings of other assessment techniques.

C. Auscultating the abdomen should be done second after inspection. This is recommended because bowel sounds should be assessed before palpation, as palpation may alter the sounds.

D. Percussion can follow auscultation, but it is not the immediate action.

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Correct Answer is B

Explanation

A. Wet-to-dry gauze dressings are typically used for more severe wounds, particularly for debridement, and are not appropriate for a stage I pressure ulcer.

B. A transparent dressing is appropriate for a stage I pressure ulcer because it provides a barrier to moisture while allowing for continuous observation of the area without disturbing the skin.

C. Hydrogel dressings are typically used for more complex wounds to hydrate and provide a moist healing environment but are not necessary for a stage I ulcer.

D. Alginate dressings are used for heavily exudating wounds and would not be appropriate for a stage I pressure ulcer.

A. Checks the instrument gauge to ensure the reading starts at zero B. Places the client's arm above the level of the client's heart C. Wraps the blood pressure cuff snugly around the client's arm D. Centers the cuff bladder over the client's brachial artery

Correct Answer is B

Explanation

A. Checking the instrument gauge to ensure it starts at zero is important for accurate readings.

B. Placing the arm above the level of the heart can result in a falsely low blood pressure reading. The arm should be at the level of the heart for an accurate measurement.

C. Wrapping the cuff snugly around the arm ensures a proper fit, which is necessary for accurate readings.

D. The bladder of the cuff should be centered over the brachial artery to obtain the most accurate reading.

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A nurse is admitting a client who requires droplet precautions due to influenza. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a stage I pressure ulcer. Which of the following dressings should the nurse plan to apply?

Correct Answer is B

Explanation

A nurse is teaching a client's partner about how to obtain a blood pressure reading. Which of the following actions by the partner indicates a need for further instruction?

Correct Answer is B

Explanation

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