A nurse is reinforcing teaching with a newly licensed nurse about measuring body temperature in clients. The nurse should instruct to obtain an oral temperature in which of the following clients? (Select all that apply.)

A client who is drinking Ice water

A client who had recent oral surgery

A client who breaths through the mouth

A client who has hemorrhoids

A client who has a coagulation disorder

Answer and Explanation

Correct Answer : D,E

A.   If a client has just consumed ice water, it can lower the oral temperature and lead to inaccurate readings. It's generally recommended to wait at least 15-30 minutes after eating or drinking before taking an oral temperature.
B.   A client who has had oral surgery may have swelling, pain, or open wounds, which could make taking an oral temperature uncomfortable and could also lead to inaccurate results. Alternative sites, such as axillary or tympanic, might be preferred.
C.   Clients who primarily breathe through their mouth may have a lower oral temperature reading due to airflow affecting the measurement. Additionally, mouth breathing can lead to inaccuracies in the reading.
D.   While hemorrhoids themselves do not affect the ability to take an oral temperature, this client is suitable for oral temperature measurement since it does not interfere with the method.
E.   A client with a coagulation disorder can typically have their oral temperature taken. There are no contraindications to taking an oral temperature in this case, as long as the client does not have any other conditions affecting their ability to do so.

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Correct Answer is ["A","B","E"]

Explanation

A. Surgical site infections (SSIs) are included in the HACRP. These infections occur at the site of a surgical procedure and can lead to increased morbidity, prolonged hospital stays, and higher healthcare costs. Therefore, this option is correct.
B. Urinary catheter-associated infections, specifically catheter-associated urinary tract infections (CAUTIs), are included in the HACRP. These infections can occur when catheters are improperly managed or remain in place longer than necessary.
C. While chest tubes can potentially lead to infections, they are not typically specified as a primary focus in the HACRP. Instead, the focus is more on more prevalent HAIs. Therefore, this option is generally not included in the HACRP.
D. Peripheral IV-associated infections are not specifically targeted in the HACRP. The program typically emphasizes central line-associated bloodstream infections rather than infections from peripheral IVs.
E. Central line-associated bloodstream infections (CLABSIs) are included in the HACRP. These infections occur when bacteria enter the bloodstream through a central line and can lead to severe complications.

A. Systolic blood pressure B. Location of blood pressure cuff C. Unit of measurement D. Position of the client

Correct Answer is B

Explanation

A. The systolic blood pressure is clearly stated as "102 mm Hg" in the documentation. There is no need for clarification regarding the systolic value.
B. It is essential to document the site where the blood pressure was taken, as this can affect the accuracy of the reading. Typically, the blood pressure is measured in the brachial artery in the upper arm. If the cuff was placed on a different site, such as the wrist or ankle, this should be noted in the documentation.
C. The unit of measurement for blood pressure is correctly indicated as "mm Hg" (millimeters of mercury). There is no need for clarification regarding the unit since it is standard and clear.
D. The position of the client is correctly documented as sitting up in a chair.

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A nurse is reinforcing teaching with a newly licensed nurse about measuring body temperature in clients. The nurse should instruct to obtain an oral temperature in which of the following clients? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with planning a staff in-service on hospital-acquired infections (HAIs). The nurse should explain that which of the following portal for types of HAIS are included in the Hospital-Acquired Condition Reduction Program (HACRP)?(Select All that Apply.)

Correct Answer is ["A","B","E"]

Explanation

A nurse is reviewing the documentation of a client's blood pressure by a newly licensed nurse. The documentation states, "Blood pressure 102/58 mm Hg. client sitting up in a chair." Which of the following information should the nurse clarify?

Correct Answer is B

Explanation

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