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 D

Explanation

Choice A reason: Wearing gloves when measuring a client's blood pressure is not typically necessary unless there is a risk of exposure to bodily fluids or if the client has an infectious disease. The use of gloves is based on the type of contact and potential for exposure, not routine tasks like BP measurement.

Choice B reason: Wearing gloves for all client contact is not necessary and is not consistent with standard precautions. Gloves should be used when there is potential contact with blood, body fluids, secretions, excretions, contaminated items, or mucous membranes.

Choice C reason: Gloves are not a substitute for hand hygiene. The primary reason for wearing gloves is to provide a barrier against infection, not to reduce handwashing. Hand hygiene is still required before donning gloves and after removing them, regardless of whether the gloves are soiled or not.

Choice D reason: Wearing gloves and a gown when bathing a client with open skin lesions is correct because it protects both the healthcare worker and the client from the risk of infection. Open skin lesions can be a source of infection, and PPE is necessary to prevent the transmission of pathogens.

A. Wash the puncture site with soap and water. B. Squeeze as much blood as possible from the puncture site. C. Flush the puncture site with water for 5 minutes. D. Begin postexposure prophylaxis the following day.

Correct Answer is A

Explanation

Choice A reason: The first step after a needlestick injury is to wash the wound with soap and water to reduce the risk of infection. This helps to remove any pathogens that may have been introduced into the puncture site.

Choice B reason: Squeezing the puncture site is not recommended because it can cause further injury to the tissue and does not effectively reduce the risk of bloodborne pathogen transmission.

Choice C reason: Flushing the puncture site with water is a good practice, but it should be done immediately, not just for 5 minutes. The initial washing is more critical.

Choice D reason: Postexposure prophylaxis (PEP) should be started as soon as possible, ideally within hours and no later than 72 hours after potential exposure to HIV. Waiting until the following day could decrease the effectiveness of PEP.

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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 reinforcing teaching with an assistive personnel (AP) about using personal protective equipment (PPE) while caring for clients. Which of the following statements should the nurse identify as an indication that the AP understands the instructions?

Correct Answer is D

Explanation

A nurse has accidentally punctured his finger with a needle he used to give an IM injection to a client. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client who reports a state of increasing anxiety and the inability to sleep and concentrate. Which of the following is an appropriate response by the nurse?

When a nurse obtains an unusually low blood pressure measurement for a client whose blood pressure is generally elevated, she considers the possibility of a problem with her technique. Which of the following sources of error should she consider as a possible cause of the low reading?

A nurse is preparing an in-service presentation about preventing healthcare-associated infections (HAIs). The nurse should include which of the following as a common cause of these infections?

A nurse is caring for a client who has a wound infection that contains vancomycin-resistant Enterococcus (VRE). Which of the following types of precautions should the nurse plan to take while caring for this client?

A nurse is reinforcing teaching about promoting rest and sleep with a client who reports insomnia. Which of the following statements should the nurse identify as an indication that the client understands the teaching?

When assessing a client's abdomen, particularly for "stomach pain," the nurse should:

A nurse is caring for a 6-month-old infant who is postoperative following a myringotomy. Which of the following pain assessment scales should the nurse use to determine the infant's pain level?

A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. The nurse enters the room to check the client's pulse. Which of the following items should the nurse wear?