A nurse is reviewing the documentation of a client's blood pressure by a newly licensed nurse. The documentation states, "Blood pressure 102/58 mm Hg. client sitting up in a chair." Which of the following information should the nurse clarify?
Systolic blood pressure
Location of blood pressure cuff
Unit of measurement
Position of the client
The Correct Answer is B
A. The systolic blood pressure is clearly stated as "102 mm Hg" in the documentation. There is no need for clarification regarding the systolic value.
B. It is essential to document the site where the blood pressure was taken, as this can affect the accuracy of the reading. Typically, the blood pressure is measured in the brachial artery in the upper arm. If the cuff was placed on a different site, such as the wrist or ankle, this should be noted in the documentation.
C. The unit of measurement for blood pressure is correctly indicated as "mm Hg" (millimeters of mercury). There is no need for clarification regarding the unit since it is standard and clear.
D. The position of the client is correctly documented as sitting up in a chair.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
A. It reflects the client’s personal feelings and experiences regarding their condition. Since it is based on
the client's report rather than measurable findings, it does not qualify as objective data.
B. It provides measurable information about the client's urine output, which can be quantified and observed by the nurse. Objective data is factual and can be verified by anyone observing the situation.
C. Like the nausea report, this statement is based on the client’s personal experience and perception of
pain. It cannot be measured objectively, making it subjective.
D. Blood pressure readings are measurable and can be objectively compared to preoperative values. This information provides concrete data regarding the client's current condition.
E. The observations of swelling and warmth can be directly assessed and are factual findings that can be confirmed by the nurse during the physical examination.
Correct Answer is A
Explanation
A. Indirect contact transmission occurs when a person touches a contaminated object or surface (fomite) and then touches their body, which can lead to infection. In this case, the client acquired the infection by touching a contaminated towel, making this an example of indirect contact transmission.
B. A vector is an organism, often an insect, that transmits pathogens from one host to another. Examples include mosquitoes transmitting malaria or ticks transmitting Lyme disease. Staphylococcus aureus does not involve a vector in its transmission; thus, this option is incorrect.
C. Droplet transmission occurs when respiratory droplets carrying infectious pathogens are expelled from an infected person and enter another person’s mucous membranes (e.g., nose, mouth, eyes) during actions like coughing or sneezing.
D. Airborne transmission involves pathogens that are carried in the air over long distances and can be inhaled by individuals. Diseases such as tuberculosis are transmitted this way. However, Staphylococcus aureus infection through touching a towel does not involve airborne transmission.
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