A nurse is reinforcing teaching with a client about monitoring her blood pressure at home with a digital device. Which of the following statements by the client indicates an understanding of the teaching?

"I will make sure my hand is about 6 inches below my heart when I use the device."

"I will check my blood pressure at a different time each day."

"I will loosely wrap the blood pressure cuff around my upper arm."

"I will know my blood pressure is too high if I get a reading of 140 over 90 or higher."

Answer and Explanation

The Correct Answer is D

This statement shows that the client understands the threshold for high blood pressure readings. A blood pressure reading of 140/90 mmHg or higher is considered elevated or hypertensive.

It is important for the client to be aware of this value and to seek medical attention or follow the prescribed management plan if their blood pressure exceeds this threshold.

The hand should be supported at the level of the heart or positioned comfortably during blood pressure measurement, but it does not need to be specifically 6 inches below the heart.

Consistency in the timing of blood pressure measurements is important for accurate monitoring. It is generally recommended to measure blood pressure at the same time each day to account for variations that can occur throughout the day.

The blood pressure cuff should be snug but not too tight around the upper arm. It should fit comfortably and securely to ensure accurate readings.

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Correct Answer is B

Explanation

Stomatitis is an inflammation of the oral mucosa, which can cause pain, discomfort, and difficulty eating. To manage stomatitis, clients should consume soft, bland foods that are easy to chew and swallow, such as cooked vegetables, mashed potatoes, and oatmeal.

Acidic, spicy, or crunchy foods should be avoided. Using lemon glycerin swabs can irritate the oral mucosa, so they should not be used.

Mouthwashes containing alcohol can cause further irritation, so they should also be avoided. Eating foods high in vitamin B12 can be helpful for preventing stomatitis, but it is not an appropriate intervention for managing an existing case of stomatitis.

A. Collect a sterile specimen from the urinary drainage bag B. Instruct the client to hold the drainage bag at waist height when ambulating C. Secure the tubing with adhesive/impe to the lower abdomen. D. Coil the tubing on the bed above the collection bag

Correct Answer is C

Explanation

A.Collecting a sterile specimen from the urinary drainage bag is incorrect because urine in the drainage bag is not considered sterile. If a sterile specimen is needed, it should be obtained by cleaning the catheter's sampling port with an antiseptic solution and withdrawing urine directly from the port using a sterile syringe.

B.Instructing the client to hold the drainage bag at waist height when ambulating is incorrect because the drainage bag should always be kept below the level of the bladder to prevent urine from flowing back into the bladder, which could lead to a urinary tract infection (UTI).

C.Securing the tubing with adhesive tape to the lower abdomen is correct because it helps prevent accidental pulling or tugging on the catheter, which could cause discomfort or dislodgement. Properly securing the tubing also helps maintain a continuous flow of urine and reduces the risk of infection.

D.Collecting a sterile specimen from the urinary drainage bag is incorrect because urine in the drainage bag is not considered sterile. If a sterile specimen is needed, it should be obtained by cleaning the catheter's sampling port with an antiseptic solution and withdrawing urine directly from the port using a sterile syringe..

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A nurse is reinforcing teaching with a client about monitoring her blood pressure at home with a digital device. Which of the following statements by the client indicates an understanding of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who has stomatitis. Which of the following instructions should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is caring for a client who has an indwelling catheter with a urinary drainage system. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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