A nurse is collecting a blood pressure (BP) reading from a client who is sitting in a chair. The nurse determines that the client's BP is 158/96 mm Hg. Which of the following actions should the nurse take?

Request that another nurse check the client's BP in 30 min.

Reposition the client supine and recheck her BP.

Recheck the client's BP in her other arm for comparison.

Ensure that the width of the BP cuff is 50% of the client's upper arm circumference

Answer and Explanation

The Correct Answer is C

A. Request that another nurse check the client's BP in 30 min:

Waiting for 30 minutes to have another nurse check the blood pressure may not be the most immediate and effective action. If there are concerns about the accuracy of the reading, rechecking the BP in the other arm promptly is a more appropriate and efficient approach.

B. Reposition the client supine and recheck her BP:

Repositioning the client supine is not necessary in this context. Blood pressure can be accurately measured while the client is sitting. Changing the position might not provide relevant information about the accuracy of the blood pressure reading.

C. Recheck the client's BP in her other arm for comparison:

This is the appropriate action. Checking the blood pressure in the other arm can help determine if there is a significant difference between the arms. A significant difference could indicate arterial disease or other issues. It's essential to confirm the accuracy of the blood pressure measurement.

D. Ensure that the width of the BP cuff is 50% of the client's upper arm circumference:

While ensuring the appropriate size of the BP cuff is essential for accurate readings, this option is not directly addressing the current situation of an elevated blood pressure reading. Checking the other arm for comparison is more relevant to assess the accuracy of the measurement.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["B","D","E"]

Explanation

A. "I need to set my hot water heater to 140 degrees Fahrenheit":
This statement is incorrect. The recommended safe temperature for a hot water heater is generally set to 120 degrees Fahrenheit (49 degrees Celsius) to prevent scalds and burns. A setting of 140 degrees Fahrenheit increases the risk of burns, especially for vulnerable populations such as children and the elderly.
B. "I will use the grab bars when getting in and out of the bathtub":
This statement indicates an understanding of the importance of using safety features, such as grab bars, to prevent falls in the bathroom. Using grab bars provides support and stability during activities like getting in and out of the bathtub, reducing the risk of accidents.
C. "I will apply tape over frayed areas of electrical cords":
This statement is incorrect. Using tape on frayed electrical cords is not a safe or effective solution. Frayed cords should be replaced to avoid the risk of electrical shock or fire. Using tape may not adequately address the underlying safety issue and can be a hazard itself.
D. "I need to check my medications for expiration dates":
This statement reflects an understanding of the importance of medication safety. Checking medication expiration dates is crucial to ensure the efficacy and safety of the medications. Expired medications may be less effective or potentially harmful.
E. "I need to have a fire escape plan with my family":
This statement shows awareness of the importance of having a fire escape plan at home. Having a plan in place helps ensure that everyone in the household knows what to do in case of a fire, improving overall safety.

A. The nurse's empathy about the client having to self-inject B. The client seeking family approval by agreeing to a teaching plan C. The nurse explaining the need for education to the client D. The client's belief that his needs will be met through education

Correct Answer is D

Explanation

A. The nurse's empathy about the client having to self-inject:

While empathy is important for building a therapeutic relationship, the client's motivation to learn is more likely to be influenced by factors directly related to their own needs and perceived benefits.

B. The client seeking family approval by agreeing to a teaching plan:

External factors, such as seeking family approval, may influence a client's willingness to participate in a teaching plan, but they might not be as effective in sustaining motivation over the long term. Intrinsic motivation tends to be more enduring and impactful.

C. The nurse explaining the need for education to the client:

While explaining the need for education is important, the client's motivation may be more influenced by their personal beliefs about the benefits of learning and meeting their own needs rather than an external explanation.

D. The client's belief that his needs will be met through education:

This statement reflects the client's intrinsic motivation, where the client perceives that learning to self-administer daily low-dose heparin injections will meet his needs. Intrinsic motivation is a powerful driver for learning because it comes from within the individual.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is collecting a blood pressure (BP) reading from a client who is sitting in a chair. The nurse determines that the client's BP is 158/96 mm Hg. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A home health nurse is teaching a client about home safety. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

A nurse is teaching a client how to self-administer daily low-dose heparin injections. Which of the following factors is most likely to increase the client's motivation to learn?

Correct Answer is D

Explanation

A nurse is preparing to administer medications to a client. At which of the following times should the nurse compare the medication administration record and the medication label? (Select all that apply.)

Client has a history of malnutrition, hyperlipidemia, and diabetes mellitus. The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for delayed wound healing? Select all that apply.

A nurse is caring for a client who has left lower-lobe atelectasis. In which of the following positions should the nurse place the client for postural drainage?

A nurse is assessing a client who received an IM antibiotic injection 15 min ago. Which of the following findings should the nurse identify as an indication of a possible anaphylactic reaction to the medication?

A nurse is caring for a client who reports that she has insomnia. Which of the following interventions is appropriate for the nurse to recommend?

A nurse is collaborating with a risk management team about potential legal issues involving client care. The nurse should identify that which of the following situations is an example of negligence?

A nurse is preparing to teach a female client about osteoporosis prevention. Which of the following recommendations should the nurse make for this client?

A nurse is planning care for a client who is scheduled for an intravenous pyelogram. Which of the following actions is appropriate for the nurse to include?