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?
Pulse 82/min, client sitting in a chair
Temperature 36.9°C (98.4°F)
Respirations auscultated, even at 22/min, client supine
Blood pressure 108/68 mm Hg
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Cleaning the incision with soap and water is not typically recommended as it can disrupt the healing process and may lead to irritation or infection. The incision should be kept clean and dry, and any cleaning should be done according to the surgeon's instructions.
Choice B reason: Performing hand hygiene before dressing changes is essential in preventing incisional infections. Hand hygiene is one of the most effective ways to prevent the spread of infections, including those at surgical sites.
Choice C reason: Protective isolation is used for immunocompromised patients to protect them from infections, not typically for postoperative patients unless they are at high risk for infection due to other conditions.
Choice D reason: Allowing the wound to air can be part of the healing process, but it must be done carefully and under the guidance of healthcare professionals to ensure that the wound is protected from contamination.
Correct Answer is B
Explanation
Choice A reason: Scarlet fever is caused by a bacterium that produces a toxin leading to a rash. It is typically spread through respiratory droplets, and while standard precautions are necessary, an N95 respirator is not required.
Choice B reason: Tuberculosis is an airborne infectious disease that requires the use of an N95 respirator to protect against inhaling the bacteria, especially in cases of pulmonary tuberculosis. This type of respirator filters out at least 95% of airborne particles, including Mycobacterium tuberculosis.
Choice C reason: Mycoplasmal pneumonia, also known as "walking pneumonia," is caused by Mycoplasma pneumoniae and is typically less severe than other types of bacterial pneumonia. Standard precautions, including the use of surgical masks, may be sufficient unless there is a risk of aerosol-generating procedures.
Choice D reason: Scabies is caused by a mite that burrows into the skin. It is spread through direct skin-to-skin contact, and an N95 respirator is not needed for protection against scabies.
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