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.

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Correct Answer is C

Explanation

Choice A reason: Not wearing artificial nails during client care is a recommended practice to prevent the spread of infection, as artificial nails can harbor bacteria.

Choice B reason: Washing hands when they are visibly dirty is correct, but hand hygiene should also be performed at other times, such as before and after patient contact, regardless of the appearance of cleanliness.

Choice C reason: Changing gloves is not a substitute for hand washing. Hand hygiene is necessary before donning gloves and after removing them to prevent the transmission of pathogens.

Choice D reason: Using alcohol-based hand products is a standard practice in healthcare settings and is effective in killing most bacteria and viruses when the hands are not visibly soiled.

A. Droplet B. Protective environment C. Airborne D. Contact

Correct Answer is B

Explanation

Choice A reason: Droplet precautions are necessary when dealing with infectious agents that are spread through large droplets expelled during coughing, sneezing, or talking. However, leukemia itself is not an infectious disease but a type of cancer affecting the blood and bone marrow. Therefore, droplet precautions are not typically required for leukemia patients unless they have a concurrent infection that warrants such measures.

Choice B reason: A protective environment refers to room designs that minimize the risk of infection in immunocompromised patients, such as those with leukemia. This includes HEPA filtration, positive air pressure rooms, and rigorous infection control practices. Given that patients with leukemia have compromised immune systems, a protective environment is crucial to protect them from infections, which can be life-threatening due to their reduced ability to fight off diseases.

Choice C reason: Airborne precautions are used for diseases that are transmitted through tiny droplets that remain suspended in the air and can be inhaled by others. Diseases like tuberculosis, measles, and chickenpox require airborne precautions. Leukemia does not require airborne precautions unless the patient has a coexisting airborne infection.

Choice D reason: Contact precautions are used for infections that are spread by direct contact with the patient or the patient's environment. While leukemia patients may be more susceptible to infections due to their compromised immune systems, contact precautions are not specifically required for leukemia itself but may be necessary if the patient has a concurrent contact-transmissible infection.

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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 a group of assistive personnel (AP) about hand hygiene. Which of the following statements by an AP should the nurse identify as an indication that the AP requires further teaching?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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