When auscultating the blood pressure, the nurse hears:
From 200 to 180 mmHg: silence; then: a thumping sound continuing down to 150
mmHg: muffled sounds continuing down to 130 mmHg; soft thumping sounds
continuing down to 105 mmHg; muffled sounds continuing down to 95 mmHg;
then silence.
The nurse records the blood pressure as _____________. - ANS ✓Answer: This blood
pressure should be recorded as 180/105/95 mmHg using the systolic/1st
diastolic/2nd diastolic convention. Rationale: Phase 1 first sound is a clear
tapping when deflation of the cuff begins. Phase 2 has a muffled, swishing sound.
In phase 3, blood is flowing freely via an increasingly open artery; sounds are
more crisp and more intense but softer than phase 1. Phase 4 sounds become
muffled and have a soft blowing quality. In phase 5 the last sound is heard
followed by silence. Cognitive Level: Analyzing Client Need: Health Promotion
and Maintenance. Nursing Process: Assessment. Learning Outcome: 29-9.
In Figure 29-28 •, which number indicates the client's oxygen saturation as
measured by pulse oximetry? _____________ - ANS ✓Answer: 4. Rationale: The SpO2
in this case is 97%. Option 1 indicates the systolic blood pressure of 121 mmHg,
option 2 the mean arterial pressure of 95 mmHg, option 3 the pulse of 87
beats/min, and option 5 the diastolic blood pressure of 84 mmHg. In addition, the
client's temperature is shown. Cognitive Level: Understanding. Client Need:
Health Promotion and Maintenance. Nursing Process: Assessment. Learning
Outcome: 29-3f.
The client is a chronic carrier of infection. To prevent the spread of the infection
to other clients or health care providers, the nurse emphasizes interventions that
do which of the following?
1. Eliminate the reservoir.
NSG 3100
, 2
NSG
2. Block the portal of exit from the reservoir.
3. Block the portal of entry into the host.
4. Decrease the susceptibility of the host. - ANS ✓Answer: 2. Rationale: Blocking
the movement of the organism from the reservoir will succeed in preventing the
infection of any other individuals. Since the carrier individual is the reservoir and
the condition is chronic, it is not possible to eliminate the reservoir (option 1).
Blocking the entry into a host (option 3) or decreasing the susceptibility of the
host (option 4) will be effective for only that one single individual and, thus, is
not as effective as blocking exit from the reservoir. Cognitive Level:
Understanding. Client Need: Safe, Effective Care Environment. Nursing Process:
Planning. Learning Outcome: 31-9
Which is the most effective nursing action for preventing and controlling the
spread of infection?
1. Thorough hand hygiene
2. Wearing gloves and masks when providing direct client care
3. Implementing appropriate isolation precautions
4. Administering broad-spectrum prophylactic antibiotics - ANS ✓Answer: 1.
Rationale: Since the hands are frequently in contact with clients and equipment,
they are the most obvious source of transmission. Regular and routine hand
hygiene is the most effective way to
prevent movement of potentially infective materials. PPE (gloves and masks) is
indicated for situations requiring standard precautions
(option 2). Isolation precautions are used for clients with known communicable
diseases (option 3). Routine use of antibiotics is not effective and can be harmful
due to the incidence of superinfection and development of resistant organisms
(option 4). Cognitive Level:
Applying. Client Need: Safe, Effective Care Environment. Nursing Process:
Implementation. Learning Outcome: 31-8.
In caring for a client on contact precautions for a draining infected foot ulcer,
which action should the nurse perform?
1. Wear a mask during dressing changes.
2. Provide disposable meal trays and silverware.
NSG 3100
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