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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Repositioning the client regularly is a critical measure to prevent pressure ulcers. This helps relieve pressure on vulnerable areas of the body and improves circulation. Turning the client every 2 hours is a common guideline to prevent prolonged pressure on any one area.
B. Keeping the head of the bed elevated continuously is not recommended as it can increase shear and friction, leading to skin breakdown.
C. Keeping the client's skin moisturized is important for maintaining skin integrity, but excessive moisture can increase the risk of skin breakdown, especially in areas susceptible to pressure ulcers. The nurse should aim to keep the skin clean, dry, and free from excessive moisture to prevent maceration.
D. Massaging bony prominences is not recommended as a preventive measure for pressure ulcers. In fact, massaging these areas can increase the risk of tissue damage due to friction and shearing forces. The focus should be on relieving pressure through proper positioning and support surfaces rather than massage.
Correct Answer is ["93.75"]
Explanation
Infusion rate (mL/hr)= Total volume (mL)/Total time (hr) 750 mL divided by 8 hours equals 93.75 mL/hr
Therefore, the nurse should set the IV pump at 94Ml/HR
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