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

Answer and Explanation

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

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Correct Answer is C

Explanation

Choice A reason: Wrapping the dressing in a clear plastic bag and discarding it in the bedside trash receptacle is not an appropriate method for disposing of soiled dressings. This approach does not comply with standard infection control protocols, as it could potentially expose healthcare workers and others to biohazardous materials.

Choice B reason: Simply discarding the dressing in the bedside trash receptacle is also inappropriate and unsafe. This method does not contain the biohazardous material properly and could lead to contamination and spread of infectious agents.

Choice C reason: Placing the dressing in a biohazardous waste container is the correct method for disposing of dressings saturated with blood and purulent drainage. According to infection control guidelines, materials that are soaked with potentially infectious agents should be disposed of in designated biohazardous waste containers. These containers are typically red or yellow and are labeled to indicate that they contain materials that require special handling.

Choice D reason: Double bagging the dressing, labeling it "biohazard," and sending it for decontamination is an unnecessary step for routine disposal of soiled dressings. While double bagging may be used in situations where there is a significant spill or leak risk, it is not typically required for standard disposal of wound dressings.

A. Providing a newborn's first bath B. Giving personal care to an infant who is HIV-positive C. Suctioning secretions from a child's newly placed tracheostomy tube D. Withdrawing cord blood from a neonate E. Transporting a cerebrospinal fluid specimen to the laboratory

Correct Answer is C

Explanation

Choice A reason: While providing a newborn's first bath, there is minimal risk of exposure to infectious fluids that would necessitate eye protection. However, standard precautions should always be followed.

Choice B reason: When giving personal care to an infant who is HIV-positive, standard precautions should be followed, which includes wearing gloves. Eye protection is not typically required unless there is a risk of splashing bodily fluids.

Choice C reason: Suctioning secretions from a child's newly placed tracheostomy tube requires eye protection because there is a high risk of secretions being expelled forcefully, which could contact the mucous membranes of the eyes.

Choice D reason: Withdrawing cord blood from a neonate generally does not require eye protection unless there is a risk of blood splatter. Standard precautions, including the use of gloves, should be sufficient.

Choice E reason: Transporting a cerebrospinal fluid specimen to the laboratory does not require the nurse to wear eye protection. However, the nurse should ensure that the specimen is sealed properly to prevent any leaks.

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For documenting vital signs, the following documentation made by the nurse indicates an understanding of the teaching:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is removing a wound dressing that is saturated with blood and purulent drainage. Which of the following methods should the nurse use when disposing of the soiled dressing?

Correct Answer is C

Explanation

A nurse is caring for a group of clients. For which of the following tasks should the nurse plan to wear protective eye equipment?

Correct Answer is C

Explanation

For the client who reports pain, the nurse should consider the following as the most reliable indicator of pain:

A nurse is changing the dressing on a client's wound. The nurse should recognize that which of the following findings is an indication of a wound infection?

Before palpating the abdomen during an assessment, the nurse should do which of the following?

A nurse is caring for a client who has pneumonia. The client's oxygen saturation is 88%. Which of the following actions should the nurse take first?

A nurse caring for a client who requires isolation has just finished a care procedure. Which of the following pieces of personal protective equipment (PPE) should the nurse remove last?

A nurse is assisting with the admission of a client who has leukemia. Which of the following transmission precautions should the nurse implement?

A nurse is reinforcing teaching with a client about healthful sleep habits. Which of the following statements should the nurse identify as an indication that the client needs further instruction?

A nurse is assisting with the admission of a client who has meningococcal pneumonia. Which of the following isolation precautions should the nurse initiate?