For documenting vital signs, the following documentation made by the nurse indicates an understanding of the teaching:
Pulse 82/min, client sitting in a chair
Temperature 36.9°C (98.4°F)
Respirations auscultated, even at 22/min, client supine
Blood pressure 108/68 mm Hg
The Correct Answer is A
Choice A reason: This documentation is correct as it includes the pulse rate and the client's position when the measurement was taken, which can affect the reading.
Choice B reason: The temperature is documented with the correct unit of measurement, but it does not specify the method of measurement (oral, axillary, tympanic, etc.), which is important for accurate interpretation.
Choice C reason: Respirations should be observed, not auscultated, and the documentation should include the client's position. The term 'even' is unnecessary and could be confusing.
Choice D reason: The blood pressure reading is correctly documented with both systolic and diastolic values. However, it should also include the client's position and the arm in which the measurement was taken for clarity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Thoroughly cleansing the affected area helps remove potential pathogens. The Centers for Disease Control and Prevention (CDC) advises washing needlestick injuries with soap and water.
Choice B reason: Squeezing the puncture site is not recommended because it can cause further injury to the tissue and does not effectively reduce the risk of bloodborne pathogen transmission.
Choice C reason: Flushing the puncture site with water is a good practice, but it should be done immediately, not just for 5 minutes. The initial washing is more critical.
Choice D reason: If indicated, postexposure prophylaxis (PEP) should be initiated as soon as possible, ideally within hours of exposure, to maximize its effectiveness. Delaying PEP until the following day is not advisable.
Correct Answer is D
Explanation
Choice A reason: Protective precautions are used to shield immunocompromised patients from infections, not typically for patients with meningococcal pneumonia.
Choice B reason: Contact precautions are used for infections that are spread by direct contact with the patient or the patient's environment. Meningococcal pneumonia is not primarily spread this way.
Choice C reason: Airborne precautions are for diseases that are spread through the air over long distances, such as tuberculosis. Meningococcal pneumonia is not spread in this manner.
Choice D reason: Droplet precautions are recommended for meningococcal pneumonia. This infection can be spread through droplets from the respiratory tract when the infected person coughs or sneezes. Therefore, droplet precautions, including the use of masks, are necessary to prevent the spread of this infection.
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