A nurse is teaching a newly licensed nurse about vital signs. Which of the following documentations made by the newly licensed nurse indicates an understanding of the teaching?
SpO2 95%
Right radial pulse regular 68/min
Temp 36°C (96.8°F)
BP 148/72 mm Hg
The Correct Answer is B
The correct answer is b.
Choice A: SpO2 95%
The normal range for SpO2, or peripheral capillary oxygen saturation, is typically between 95% and 100%. While a SpO2 of 95% is within the normal range, it doesn't necessarily indicate an understanding of vital signs as it's on the lower end of the normal range.
Choice B: Right radial pulse regular 68/min
The normal resting heart rate for adults ranges from 60 to 100 beats per minute. Therefore, a right radial pulse of 68 beats per minute falls within the normal range and indicates an understanding of vital signs.
Choice C: Temp 36°C (96.8°F)
The normal body temperature for a healthy adult can range from 97.8°F (36.5°C) to 99.1°F (37.3°C). Therefore, a body temperature of 36°C (96.8°F) is slightly below the normal range.
Choice D: BP 148/72 mm Hg
The normal range for blood pressure in adults is between 90/60 mmHg and 120/80 mmHg. A blood pressure reading of 148/72 mm Hg is above the normal range for systolic pressure (the top number), indicating high blood pressure (hypertension).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Answer: C. Place a surgical mask on the client when they leave their room.
Rationale:
A) Wear a surgical mask when within 0.6 m (2 ft) of the client.
While it is necessary to wear a surgical mask when in close proximity to a client on droplet precautions, the distance specified (0.6 m or 2 ft) is less than the standard recommended distance of 1 meter (3 feet). Therefore, this option is not fully aligned with best practices.
B) Move the client to a positive airflow room.
Positive airflow rooms are typically used for clients with immunosuppression or those who need protection from airborne pathogens, not for those on droplet precautions. This action is not appropriate for a client requiring droplet precautions.
C) Place a surgical mask on the client when they leave their room.
This action is appropriate and essential to minimize the risk of transmission of infectious agents to others when the client is moving outside their isolation area. The client wearing a mask is a key part of droplet precautions.
D) Remove fresh flowers from the client’s room.
While it may be necessary to remove fresh flowers in certain cases (such as for neutropenic clients), this is not specifically related to droplet precautions. Droplet precautions focus primarily on respiratory secretions and do not directly involve the presence of flowers.
Correct Answer is D
Explanation
In case of a fire, it is important to contain the smoke and flames by closing all doors . This can help prevent the spread of fire and smoke to other areas of the hospital and provide more time for evacuation. After
closing all doors, the nurse should follow the hospital’s fire safety plan and take further actions as necessary.
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