A nurse has completed the client's initial assessment and is preparing to identify abnormal data and the client's strengths. Which of the following is required to successfully complete this phase of the nursing process?

Understanding of the referral process.

Recognition of the client's medical prognosis.

Drawing inferences about the client.

Knowledge of anatomy and physiology.

Answer and Explanation

The Correct Answer is C

A. Understanding the referral process is important for coordinating care but is not required to identify abnormal data and client strengths.
B. While knowing the medical prognosis can provide context, the nursing process focuses on holistic client assessment rather than medical diagnosis.
C. Drawing inferences about the client is correct because analyzing the collected data allows the nurse to recognize patterns, identify potential health problems, and determine the client’s strengths.
D. Knowledge of anatomy and physiology is valuable, but interpretation and clinical judgment (drawing inferences) are crucial for identifying abnormal data.

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Correct Answer is A

Explanation

A. Inflating the blood pressure cuff 30 mmHg above the point where the radial pulse disappears is correct. This method, known as the palpatory method, prevents auscultatory gap errors and ensures an accurate blood pressure reading.
B. Assisting the patient to a standing position for five to ten minutes is incorrect unless assessing for orthostatic hypotension. For routine blood pressure measurements, the client should be seated and at rest for at least five minutes.
C. Palpating the radial artery and placing the stethoscope lightly over this area is incorrect because blood pressure is auscultated over the brachial artery, not the radial artery.
D. Measuring the blood pressure cuff to encircle 60% of the client’s arm is incorrect. The correct guideline is that the cuff bladder should encircle at least 80% of the arm circumference, not 60%.

A. Reassess the blood pressure measurement. B. Notify the provider. C. Recheck the blood pressure measurement in 30 minutes. D. Have the patient care tech take the blood pressure measurement again.

Correct Answer is A

Explanation

A. Reassessing the blood pressure measurement is correct because the nurse should always verify abnormal findings before taking further action. The initial reading could be due to equipment error, improper cuff size, or patient positioning.
B. Notifying the provider is incorrect at this time because the nurse should first confirm the accuracy of the reading before escalating concerns.
C. Rechecking the BP in 30 minutes is incorrect because if the reading is accurate, waiting 30 minutes could delay necessary interventions.
D. Having the patient care tech take the BP again is incorrect because the nurse should personally validate the abnormal finding rather than delegating it.

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A nurse has completed the client's initial assessment and is preparing to identify abnormal data and the client's strengths. Which of the following is required to successfully complete this phase of the nursing process?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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