The nurse is preparing to assess a hospitalized patient who is ...

[mynx]

The nurse is preparing to assess a hospitalized patient who is experiencing significant shortness of breath. How should the nurse proceed with the assessment?
 
  a. The patient should lie down to obtain an accurate cardiac, respiratory, and abdominal assessment.
  b. A thorough history and physical assessment information should be obtained from the patient's family member.
  c. A complete history and physical assessment should be immediately performed to obtain baseline information.
  d. Body areas appropriate to the problem should be examined and then the assessment completed after the problem has resolved.

Question 2

Which of these statements is true regarding the use of Standard Precautions in the health care setting?
 
  a. Standard Precautions apply to all body fluids, including sweat.
  b. Use alcohol-based hand rub if hands are visibly dirty.
  c. Standard Precautions are intended for use with all patients, regardless of their risk or presumed infection status.
  d. Standard Precautions are to be used only when nonintact skin, excretions containing visible blood, or expected contact with mucous membranes is present.

[marict]

Answer to Question 1

ANS: D
Both altering the position of the patient during the examination and collecting a mini database by examining the body areas appropriate to the problem may be necessary in this situation. An assessment may be completed later after the distress is resolved.

Answer to Question 2

ANS: C
Standard Precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources and are intended for use for all patients, regardless of their risk or presumed infection status. Standard Precautions apply to blood and all other body fluids, secretions and excretions except sweatregardless of whether they contain visible blood, nonintact skin, or mucous membranes. Hands should be washed with soap and water if visibly soiled with blood or body fluids. Alcohol-based hand rubs can be used if hands are not visibly soiled.

[mynx]

Excellent

[diana chang]

TYSM