An assistive personnel (AP) asks a nurse what precautions he should take when measuring the vital signs of a client who has pneumonia. Which of the following responses should the nurse make?

"Wear a mask when entering the client's room."

"Gloves are not necessary if you wash your hands well."

"Place a mask on the client when you check her vital signs."

"Wear a gown whenever you come in close contact with the client."

Answer and Explanation

The Correct Answer is A

A.   Wearing a mask helps prevent the spread of respiratory droplets that may contain infectious pathogens, such as those causing pneumonia. It protects both the client from potential pathogens carried by the AP and the AP from potential exposure to the client's respiratory secretions.

B.   Gloves should be worn when there is a risk of contact with the client's body fluids, including respiratory secretions, to prevent transmission of infectious agents. Hand hygiene (washing hands well) is important but does not replace the need for gloves in situations where there is a risk of exposure to bodily fluids.
C.   Placing a mask on the client would not typically be required unless the client is coughing excessively and the mask is intended to contain respiratory droplets. However, the focus of precautions should primarily be on protecting the AP.
D.   Wearing a gown may be necessary if there is a risk of contamination with respiratory secretions or if the AP anticipates contact with the client's body fluids. However, it is not specifically required for routine vital sign measurement unless there is visible contamination or extensive contact with the client's secretions.

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Correct Answer is A

Explanation

A. Body weight is one of the most reliable indicators of fluid status in a dialysis patient. Before and after each hemodialysis session, the nurse should weigh the client using the same scale under similar conditions (e.g., same clothing). The difference in weight reflects fluid loss during the dialysis treatment. This measurement helps guide adjustments in fluid management and dialysis prescriptions.
B. Abdominal girth can increase due to fluid accumulation in the abdomen (ascites) but is less specific for measuring fluid losses during dialysis. It may be more indicative of fluid retention over a longer period rather than immediate changes related to a single dialysis session.
C. Neck vein distention can be a sign of fluid overload but is not typically used to assess fluid losses during dialysis. It may be more relevant for assessing fluid status over time rather than immediate changes post- dialysis.
D. Blood pressure can fluctuate based on various factors, including fluid status. While blood pressure monitoring is essential in dialysis patients, it alone does not reliably reflect fluid losses during dialysis sessions.

A. Administer glucagon IM. B. Check the client for a positive Chvostek's sign. C. Request a potassium replacement. D. Discontinue the TPN infusion.

Correct Answer is C

Explanation

A. Glucagon is administered to increase blood glucose levels in hypoglycemic states. However, the client's glucose level is within the normal range (72 mg/dL), so administering glucagon is not appropriate.

B. Chvostek's sign is assessed to detect hypocalcemia, not hypokalemia. It involves tapping the facial nerve anterior to the earlobe and observing for facial muscle contraction. This action is not relevant to the potassium level and is not indicated based on the laboratory findings provided.
C. The client's potassium level of 3.0 mEq/L is below the normal range, indicating hypokalemia. Potassium replacement is essential to prevent complications such as cardiac arrhythmias. The nurse should follow the facility's protocol for administering potassium replacement, which may include adjusting the TPN solution or administering intravenous potassium supplements.
D. Discontinuing the TPN infusion is not warranted based solely on the potassium level. The TPN infusion provides essential nutrition and should not be stopped without addressing the electrolyte imbalance separately.

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An assistive personnel (AP) asks a nurse what precautions he should take when measuring the vital signs of a client who has pneumonia. Which of the following responses should the nurse make?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving hemodialysis. Which of the following client measurements should the nurse compare before and after dialysis treatment to determine fluid losses?

Correct Answer is A

Explanation

A nurse is reviewing the laboratory values of a client who is receiving total parenteral nutrition (TPN): glucose 72 mg/dL, chloride 100 mEq/L. sodium 138 mEq/L and potassium 3.0 mEq/L. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

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