An assistive personnel (AP) asks a nurse what precautions he should take when measuring the vital signs of a client who has pneumonia. Which of the following responses should the nurse make?

"Wear a mask when entering the client's room."

"Gloves are not necessary if you wash your hands well."

"Place a mask on the client when you check her vital signs."

"Wear a gown whenever you come in close contact with the client."

Answer and Explanation

The Correct Answer is A

A.   Wearing a mask helps prevent the spread of respiratory droplets that may contain infectious pathogens, such as those causing pneumonia. It protects both the client from potential pathogens carried by the AP and the AP from potential exposure to the client's respiratory secretions.

B.   Gloves should be worn when there is a risk of contact with the client's body fluids, including respiratory secretions, to prevent transmission of infectious agents. Hand hygiene (washing hands well) is important but does not replace the need for gloves in situations where there is a risk of exposure to bodily fluids.
C.   Placing a mask on the client would not typically be required unless the client is coughing excessively and the mask is intended to contain respiratory droplets. However, the focus of precautions should primarily be on protecting the AP.
D.   Wearing a gown may be necessary if there is a risk of contamination with respiratory secretions or if the AP anticipates contact with the client's body fluids. However, it is not specifically required for routine vital sign measurement unless there is visible contamination or extensive contact with the client's secretions.

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Correct Answer is B

Explanation

A. Mouth care is an important aspect of overall care, but it is not directly related to chest percussion, vibration, and postural drainage. It can be done before or after these procedures as needed for client comfort and oral hygiene.
B. Auscultating the lung fields is a crucial step before initiating chest percussion, vibration, and postural drainage. It helps the nurse assess the current status of lung sounds, identify areas of congestion or consolidation, and determine the appropriate areas for percussion and drainage.
C. Positioning the client correctly is essential to facilitate effective drainage. By positioning the lung area to be drained above the trachea, gravity assists in moving secretions towards the larger airways for removal.
D. Chest percussion involves rhythmically tapping the chest wall with cupped hands to loosen and mobilize secretions in the lungs. This action helps to facilitate drainage during postural drainage.

A. Muscle hypotonicity B. Positive Chvostek's sign C. Diarrhea D. Tachycardia

Correct Answer is D

Explanation

A. Hypercalcemia can lead to muscle weakness and fatigue rather than hypotonicity. High calcium levels affect neuromuscular function, potentially causing muscle weakness and decreased muscle tone rather than increased flaccidity.
B. Chvostek's sign is a clinical sign of hypocalcemia, not hypercalcemia. It is characterized by facial muscle twitching in response to tapping the facial nerve just anterior to the ear. Therefore, a positive Chvostek's sign would not be expected in hypercalcemia.
C. Hypercalcemia can cause gastrointestinal disturbances such as constipation rather than diarrhea. High calcium levels can lead to decreased smooth muscle contractility in the intestines, resulting in constipation rather than increased motility leading to diarrhea.
D. Hypercalcemia can lead to a variety of cardiovascular effects, including arrhythmias. Tachycardia can occur as a result of increased sensitivity of the heart to catecholamines and altered electrical conductivity in hypercalcemia.

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An assistive personnel (AP) asks a nurse what precautions he should take when measuring the vital signs of a client who has pneumonia. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the plan of care for a client who has pneumonia and requires chest percussion, vibration, and postural drainage. Which of the following actions should the nurse plan to complete first?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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