Prior to taking the health history, the nurse should first do which of the following?

Offer the client a beverage of choice

Establish that insurance coverage exists

Establish a rapport with the patient

Ask the patient to disrobe and put on a gown

Answer and Explanation

The Correct Answer is C

Choice A reason: Offering a beverage is a hospitable gesture but not the first step in taking a health history. The priority is to establish communication and trust.

Choice B reason: Confirming insurance coverage is important but not the initial step in the health history process. The focus should first be on the patient's immediate needs and concerns.

Choice C reason: Establishing a rapport with the patient is the first and most crucial step in taking a health history. It involves creating a comfortable and trusting environment for the patient to share personal health information.

Choice D reason: Asking the patient to disrobe and put on a gown may be necessary for a physical examination but is not the first step in taking a health history. The nurse should first establish a rapport with the patient.

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Correct Answer is A

Explanation

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.

A. Wrap the dressing in a clear plastic bag and discard it in the bedside trash receptacle. B. Discard the dressing in the bedside trash receptacle. C. Place the dressing in a biohazardous waste container. D. Double bag the dressing, label it "biohazard," and send it for decontamination.

Correct Answer is C

Explanation

Choice A reason: Wrapping the dressing in a clear plastic bag and discarding it in the bedside trash receptacle is not an appropriate method for disposing of soiled dressings. This approach does not comply with standard infection control protocols, as it could potentially expose healthcare workers and others to biohazardous materials.

Choice B reason: Simply discarding the dressing in the bedside trash receptacle is also inappropriate and unsafe. This method does not contain the biohazardous material properly and could lead to contamination and spread of infectious agents.

Choice C reason: Placing the dressing in a biohazardous waste container is the correct method for disposing of dressings saturated with blood and purulent drainage. According to infection control guidelines, materials that are soaked with potentially infectious agents should be disposed of in designated biohazardous waste containers. These containers are typically red or yellow and are labeled to indicate that they contain materials that require special handling.

Choice D reason: Double bagging the dressing, labeling it "biohazard," and sending it for decontamination is an unnecessary step for routine disposal of soiled dressings. While double bagging may be used in situations where there is a significant spill or leak risk, it is not typically required for standard disposal of wound dressings.

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Prior to taking the health history, the nurse should first do which of the following?

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Naxlex Comprehensive Predictor Exams

For documenting vital signs, the following documentation made by the nurse indicates an understanding of the teaching:

Correct Answer is A

Explanation

A nurse is removing a wound dressing that is saturated with blood and purulent drainage. Which of the following methods should the nurse use when disposing of the soiled dressing?

Correct Answer is C

Explanation

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