An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1° C (98.8° F), pulse 92/min, respiratory rate 18/min, and BP 88/58 mm Hg. Which of the following vital signs should the nurse re-measure?

Respiratory rate.

Temperature.

Pulse rate.

BP.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Re-measuring the respiratory rate is unnecessary. The reported respiratory rate falls within the normal range of 12-20 breaths per minute for adults.

Choice B rationale:

Re-measuring the temperature is the correct action. Tympanic temperature measurements can be influenced by factors such as earwax buildup, ear infection, or improper placement of the thermometer. Repeating the temperature measurement ensures accuracy.

Choice C rationale:

Re-measuring the pulse rate is unnecessary. The reported pulse rate of 92 beats per minute falls within the normal range of 60-100 beats per minute for adults.

Choice D rationale:

Re-measuring the blood pressure is unnecessary. The reported blood pressure of 88/58 mm Hg, while at the lower end of the normal range (typically around 90/60 mm Hg), is not excessively low and doesn't indicate an immediate need for concern.

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Correct Answer is B

Explanation

Choice A rationale:

Enclosing the dressing in a single clear plastic bag and discarding it in the bedside trash receptacle is not the appropriate method for disposing of a dressing saturated with blood and purulent drainage. Blood and purulent drainage are considered potentially infectious materials, and they should be handled as biohazardous waste to prevent the spread of infection.

Choice B rationale:

This is the correct choice. When dealing with potentially infectious materials such as blood and purulent drainage, it's essential to dispose of them in a biohazardous waste container. This specialized container is designed to contain potentially infectious materials and prevent their spread, thereby protecting both healthcare workers and the environment.

Choice C rationale:

Discarding the dressing in the bedside trash receptacle is not the recommended approach for disposing of materials that are contaminated with blood and purulent drainage. Simply discarding it in the regular trash increases the risk of infection transmission and is not compliant with proper infection control practices.

Choice D rationale:

Double-bagging the dressing in clear bags and labeling it "biohazard" is a good practice to ensure proper containment. However, it's not the most comprehensive method of disposal. Placing the dressing in a dedicated biohazardous waste container is a more secure and standardized method for disposing of potentially infectious materials.

A. Pigeon. B. Funnel. C. Kyphotic. D. Barrel.

Correct Answer is D

Explanation

Choice A rationale:

The choice "Pigeon" is not the correct answer. Pigeon chest, also known as pectus carinatum, is a deformity of the chest characterized by a protrusion of the sternum and ribs. This condition is not associated with chronic bronchitis.

Choice B rationale:

The choice "Funnel" is not the correct answer. Funnel chest, or pectus excavatum, is a deformity where the sternum is sunken into the chest. It is not the expected chest shape in chronic bronchitis.

Choice C rationale:

The choice "Kyphotic" is not the correct answer. Kyphosis refers to an excessive outward curvature of the thoracic spine, leading to a rounded upper back appearance. This is not the typical chest shape seen in chronic bronchitis.

Choice D rationale:

The correct answer is "Barrel." Choice D is the correct answer. Chronic bronchitis is a type of chronic obstructive pulmonary disease (COPD) characterized by airway inflammation and narrowing. Over time, this can lead to air trapping in the lungs and an increase in the anteroposterior diameter of the chest. This results in a barrel-shaped chest appearance, where the chest appears rounded and the ribs are more horizontal. This adaptation allows for increased lung capacity to accommodate for the compromised airflow in patients with chronic bronchitis.

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An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1° C (98.8° F), pulse 92/min, respiratory rate 18/min, and BP 88/58 mm Hg. Which of the following vital signs should the nurse re-measure?

Nursing Test Bank

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Correct Answer is B

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Correct Answer is D

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