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 C

Explanation

A. This description is more indicative of a stage 1 pressure ulcer, where the skin is intact but shows non- blanchable redness. Stage 1 ulcers do not involve skin loss.
B. This description might indicate a stage 2 pressure ulcer, where there is partial-thickness skin loss involving the epidermis and/or dermis. Stage 2 ulcers are characterized by shallow open ulcers with a red- pink wound bed, without slough.
C. This description accurately defines a stage 3 pressure ulcer. Stage 3 ulcers involve full-thickness skin loss where adipose (fat) tissue may be visible, but deeper structures such as muscle, tendon, and bone are not exposed.
D. Slough refers to yellow, tan, gray, green, or brown necrotic tissue in the wound bed that must be removed to facilitate wound healing. Slough can be present in both stage 3 and stage 4 pressure ulcers, where stage 4 involves full-thickness skin loss with exposure of muscle, bone, or supporting structures.

A. Positioning the client's arm above heart level B. Wrapping the cuff too loosely around the client's arm C. Deflating the cuff too slowly D. Measuring blood pressure right after the client's mealtime

Correct Answer is A

Explanation

A. Positioning the client's arm above heart level can result in a falsely low blood pressure reading. This is because gravity assists in the flow of blood downward, artificially reducing the pressure measured in the arteries. For accurate blood pressure measurement, the client's arm should be positioned at heart level or slightly below heart level.
B. If the blood pressure cuff is wrapped too loosely around the client's arm, it can lead to inaccurate readings. A loose cuff may allow leakage of air during inflation or may not provide sufficient compression to accurately detect the arterial pressure pulses.
C. Deflating the cuff too slowly can cause a falsely high diastolic pressure reading. When the cuff is deflated slowly, the pressure in the cuff remains close to the systolic pressure for a longer duration, leading to incorrect readings, especially in diastolic pressure.
Blood pressure can temporarily increase after meals due to digestion, particularly in clients with hypertension. Measuring blood pressure immediately after a meal may result in a higher reading that does not reflect the client's baseline blood pressure. However, this would typically lead to a higher reading rather than a lower one.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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