A nurse is collecting data from a client who has chronic kidney failure. An assistive personnel reports that the client has a blood pressure of 190/110 mm Hg. Which of the following actions should the nurse take first?

Remeasure the client's blood pressure.

Administer an antihypertensive medication.

Report the blood pressure reading to the charge nurse.

Instruct the client to remain in bed.

Answer and Explanation

The Correct Answer is A

Choice A reason: Remeasuring confirms the 190/110 mm Hg reading, ensuring accuracy in kidney failure, where hypertension is common. It’s the first step before acting.

Choice B reason: Administering medication without verification risks error; BP may be inaccurate. In kidney failure, precise BP guides therapy, so this waits.

Choice C reason: Reporting to the charge nurse follows confirmation; unverified readings waste time. Accuracy in chronic kidney failure is critical before escalating.

Choice D reason: Bed rest may help, but confirming BP first prioritizes data. Kidney failure needs validated hypertension readings to direct immediate care safely.

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Correct Answer is C

Explanation

Choice A reason: Taping to the cheek risks skin injury and tube displacement in kids. Abdominal securing is safer for gastrostomy stability and comfort.

Choice B reason: Extension tubes are for feeding, not routine site care. Attaching one now is premature, unrelated to maintaining the site itself.

Choice C reason: Securing to the abdomen prevents pulling or dislodgement of the gastrostomy tube. It’s a standard care step, ensuring stability and safety.

Choice D reason: Lubricant isn’t needed for site care; it may irritate skin. Clean, dry maintenance is preferred, making this an incorrect action.

A. Social worker B. Advanced practice nurse C. Patient care technician D. Psychologist

Correct Answer is B

Explanation

Choice A reason: Social workers address psychosocial needs, not drug interactions. Medication queries require clinical expertise beyond their scope in this context.

Choice B reason: Advanced practice nurses have prescribing and pharmacology knowledge, ideal for assessing interactions. They’re the best referral for this clinical question.

Choice C reason: Patient care technicians assist with basic care, lacking drug interaction training. They can’t evaluate complex medication profiles adequately here.

Choice D reason: Psychologists focus on mental health, not pharmacokinetics. They lack the medical expertise to address physical drug interaction concerns effectively.

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A nurse is collecting data from a client who has chronic kidney failure. An assistive personnel reports that the client has a blood pressure of 190/110 mm Hg. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing site care for a child who has a gastrostomy enteral tube. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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