The nurse is assessing the client's vital signs and is aware that which assessment data requires immediate attention?

Choice A rationale:

Healthcare-associated infections (HAIs) do not necessarily occur due to compromised immunity. HAIs refer to infections that patients acquire while receiving treatment for medical or surgical conditions, and they can happen to individuals with varying levels of immunity.

Choice B rationale:

While infections during therapeutic procedures are a concern, not all healthcare-associated infections occur during such procedures. HAIs can happen in various healthcare settings and not limited to therapeutic procedures.

Choice C rationale:

Inhaling pathogens in a healthcare setting might lead to infections, but not all healthcare-associated infections happen due to inhalation. HAIs can occur through different modes of transmission.

Choice D rationale:

Healthcare-associated infections (HAIs) occur when a patient acquires an infection while receiving care in a healthcare setting, including hospitals. This can involve various sources, such as contaminated medical equipment, surgical procedures, or interactions with healthcare personnel.

Choice A rationale:

This option is incorrect. Counting a regular pulse for 30 seconds and doubling the number is an appropriate method for assessing heart rate, not peripheral pulses. When assessing peripheral pulses, it is important to count the pulses directly for a full minute to accurately determine the pulse rate. This ensures that any irregularities or variations in the pulse rate are captured.

Choice B rationale:

This option is incorrect. Palpating the femoral artery in the groin is a standard method for assessing peripheral pulses. It is not a safety issue when performed correctly. However, the question asks about a safety issue related to assessing peripheral pulses.

Choice C rationale:

Palpating both carotid pulses at the same time is a safety issue when assessing peripheral pulses. Simultaneously palpating both carotid pulses can lead to excessive pressure on the carotid sinuses, which are baroreceptors located in the carotid arteries. Stimulation of these baroreceptors can result in a reflex decrease in heart rate and blood pressure, leading to a condition known as carotid sinus hypersensitivity. This can cause dizziness, fainting, or, in extreme cases, cardiac arrest. Therefore, it is essential to avoid palpating both carotid pulses simultaneously to prevent adverse reactions in clients, especially those with cardiovascular issues.

Choice D rationale:

Palpating the radial artery on the thumb side of the wrist is a standard method for assessing peripheral pulses. It is a safe and commonly used technique for evaluating radial pulse rate, rhythm, and amplitude. .