A nurse is reinforcing teaching with a newly licensed nurse about documenting vital signs. Which of the following documentation made by the nurse indicates an understanding of the teaching?

Choice A reason: Urinary catheterization is a well-known risk factor for HAIs, particularly catheter-associated urinary tract infections (CAUTIs). The use of indwelling urinary catheters can introduce bacteria into the urinary tract and is associated with a significant proportion of HAIs.

Choice B reason: While malnutrition can affect the immune system and increase the risk of infections, it is not a direct cause of HAIs. Good nutritional status is important for wound healing and infection prevention, but it does not cause HAIs by itself.

Choice C reason: Having multiple caregivers can increase the risk of transmitting infections, especially if hand hygiene and other infection control practices are not consistently followed. However, it is not considered a direct cause of HAIs like urinary catheterization is.

Choice D reason: Chlorhexidine washes are actually used as a preventive measure against HAIs, particularly in reducing the risk of surgical site infections. They are not a cause of HAIs but rather part of the solution to prevent them.

Choice A reason: Documenting the pulse as "82/min, client sitting in a chair" is correct and shows an understanding of the teaching. The pulse rate is within the normal range for a resting adult, which is typically between 60 to 100 beats per minute. Additionally, noting the client's position is important as body position can affect pulse rate; sitting can slightly increase the pulse compared to lying down.

Choice B reason: The temperature of "36.9°C (98.4°F)" is within the normal range for body temperature, which is typically between 36.5°C to 37.5°C (97.7°F to 99.5°F). Documenting the temperature in both Celsius and Fahrenheit is a good practice, as it provides clarity and prevents confusion in clinical settings where different systems may be used.

Choice C reason: The documentation of respirations as "auscultated, even at 22/min, client supine" is appropriate. The normal respiratory rate for a healthy adult at rest is between 12 to 20 breaths per minute. Noting that the respirations are even and the client's position is supine is important, as different positions can affect breathing patterns and rates.

Choice D reason: A blood pressure reading of "108/68 mm Hg" falls within the normal range, which is generally considered to be between 90/60 mm Hg and 120/80 mm Hg for adults. Proper documentation of blood pressure includes both systolic and diastolic values, as seen here, which is essential for accurate monitoring and treatment decisions.