The nurse is assessing the client's vital signs and is aware that which assessment data requires immediate attention?

An oral temperature of 100°F (37.8°C)

A respiratory rate of 30/min.

A radial pulse of 45 beats in 30 seconds.

A blood pressure of 114/74 mmHg.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

An oral temperature of 100°F (37.8°C) is within the normal range for body temperature, which typically ranges from 97.8°F to 99.1°F (36.5°C to 37.3°C) While it's essential to monitor temperatures, this value does not require immediate attention.

Choice B rationale:

A respiratory rate of 30/min is a concerning finding. The normal respiratory rate for adults at rest is typically between 12 to 20 breaths per minute. A rate of 30/min suggests tachypnea (rapid breathing), which can be a sign of various underlying medical issues, including respiratory distress or metabolic acidosis. This requires immediate attention and further assessment.

Choice C rationale:

A radial pulse of 45 beats in 30 seconds can be translated to a pulse rate of 90 beats per minute, which falls within the normal range for adults (60 to 100 beats per minute) While it's important to monitor pulse rates, this value does not require immediate attention.

Choice D rationale:

A blood pressure of 114/74 mmHg is within the normal range for blood pressure in adults. Normal blood pressure typically ranges around 120/80 mmHg, but variations within a few points are considered normal. This blood pressure reading does not require immediate attention.

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Correct Answer is A

Explanation

Choice A rationale:

Proper hand-washing technique involves washing hands for at least 20 seconds. This duration ensures thorough cleansing and removal of germs, dirt, and contaminants from the hands. Washing for a shorter time, such as 10 seconds (Choice B), may not effectively eliminate all harmful microorganisms, increasing the risk of infections and transmission of diseases.

Choice B rationale:

Washing hands for only 10 seconds is insufficient to achieve the necessary level of cleanliness. It is essential to follow recommended guidelines to prevent the spread of infections in healthcare settings and other environments where hygiene is crucial.

Choice C rationale:

Washing hands for 45 seconds (Choice C) is longer than the recommended duration and might not be practical, especially in busy healthcare settings. While thorough hand hygiene is essential, excessively long washing times could lead to reduced compliance among healthcare workers, potentially compromising patient safety.

Choice D rationale:

Proper hand-washing technique involves scrubbing hands for at least 20 seconds, making Choice D incorrect. Following the recommended guidelines is crucial to maintaining a safe and hygienic healthcare environment.

A. Wear a mask when entering the client's room. B. Remove potted plants from the room. C. Allow the client to leave the room every 2 hours. D. Dedicate equipment and supplies for use with the client.

Correct Answer is D

Explanation

Choice A rationale:

Healthcare-associated infections (HAIs) do not necessarily occur due to compromised immunity. HAIs refer to infections that patients acquire while receiving treatment for medical or surgical conditions, and they can happen to individuals with varying levels of immunity.

Choice B rationale:

While infections during therapeutic procedures are a concern, not all healthcare-associated infections occur during such procedures. HAIs can happen in various healthcare settings and not limited to therapeutic procedures.

Choice C rationale:

Inhaling pathogens in a healthcare setting might lead to infections, but not all healthcare-associated infections happen due to inhalation. HAIs can occur through different modes of transmission.

Choice D rationale:

Healthcare-associated infections (HAIs) occur when a patient acquires an infection while receiving care in a healthcare setting, including hospitals. This can involve various sources, such as contaminated medical equipment, surgical procedures, or interactions with healthcare personnel.

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The nurse is assessing the client's vital signs and is aware that which assessment data requires immediate attention?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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