A nurse is reviewing the documentation of a client's blood pressure by a newly licensed nurse.
The documentation states, "Blood pressure 102/58 mm Hg, client sitting up in a chair.”. Which of the following information should the nurse clarify?

Systolic blood pressure.

Position of the client.

Unit of measurement.

Location of blood pressure cuff.

Answer and Explanation

The Correct Answer is D

The correct answer is choice d. Location of blood pressure cuff.

Choice A rationale: The systolic blood pressure of 102 mm Hg is within a normal range and does not require clarification.

Choice B rationale: The position of the client, “sitting up in a chair,” is clearly documented and does not need further clarification.

Choice C rationale: The unit of measurement, “mm Hg,” is the standard unit for blood pressure and is correctly documented.

Choice D rationale: The location of the blood pressure cuff is not specified in the documentation. It is important to document whether the blood pressure was taken on the left or right arm, or another location, to ensure accuracy and consistency in future measurements.

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 D

Explanation

Atrial fibrillation with a rapid heart rate can lead to decreased cardiac output and compromised blood flow, which can have serious consequences, including stroke and heart failure. Therefore, this client requires immediate attention to assess and manage the cardiac rhythm.

While the other clients also have significant health concerns, they are not as acutely life-threatening as a new onset of atrial fibrillation with a high heart rate. Prioritizing care based on the urgency and severity of the condition is crucial in the emergency department setting.

A. Budesonide 6 mg PO daily B. BMI: 16 C. History of type 2 diabetes mellitus D. New diagnosis of Crohn's disease E. Hematocrit (Hct): 47% F. Hemoglobin (Hgb): 16 g/dL G. Potassium: 3.6 mEq/L

Correct Answer is ["A","B","C","D"]

Explanation

Findings that Could Increase Susceptibility to Infection:

Budesonide 6 mg PO daily:
- Explanation: Budesonide is a corticosteroid used to reduce inflammation, often prescribed for conditions like Crohn's disease. While it helps manage inflammation, corticosteroids also suppress the immune system. This immunosuppressive effect can increase the client's susceptibility to infections.
BMI of 16:
- Explanation: A BMI of 16 is considered underweight. Malnutrition or being underweight can weaken the immune system, making a person more susceptible to infections because their body lacks the necessary nutrients and energy to support immune function.
History of Type 2 Diabetes Mellitus:
- Explanation: Diabetes, particularly if not well-controlled, can impair the immune system and increase the risk of infections. High blood sugar levels can hinder the function of immune cells, making it easier for infections to develop and harder for the body to fight them.
New Diagnosis of Crohn's Disease:
- Explanation: Crohn's disease is an inflammatory bowel disease that causes inflammation of the digestive tract. This chronic inflammation can affect the body's ability to absorb nutrients, leading to nutritional deficiencies that impair the immune system. Additionally, the disease itself, especially when active, can increase the risk of infection.

Findings That Do Not Increase Susceptibility to Infection:

Hematocrit (Hct) of 47%:
- Explanation: The Hct level is within the normal range of 37% to 52%. It measures the percentage of red blood cells in the blood. Since it's normal, it does not indicate an increased risk of infection.
Hemoglobin (Hgb) of 16 g/dL:
- Explanation: The Hgb level is also within the normal range of 12 to 18 g/dL. Hemoglobin is a protein in red blood cells that carries oxygen. This normal level does not suggest a higher risk of infection.
Potassium level of 3.6 mEq/L:
- Explanation: Potassium levels are within the normal range of 3.5 to 5.0 mEq/L. This electrolyte level is unrelated to infection risk in the context provided.

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 reviewing the documentation of a client's blood pressure by a newly licensed nurse. The documentation states, "Blood pressure 102/58 mm Hg, client sitting up in a chair.”. Which of the following information should the nurse clarify?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is performing triage on a group of clients. Which of the following clients should the nurse see first?

Correct Answer is D

Explanation

Correct Answer is ["A","B","C","D"]

Explanation

Findings that Could Increase Susceptibility to Infection:

Findings That Do Not Increase Susceptibility to Infection:

A nurse is preparing an educational session about The Joint Commission (TJC). Which of the following information should the nurse include?

A nurse is providing an in-service to a group of newly licensed nurses on standards of practice and the role of the Board of Nursing (BON). Which of the following information should the nurse include?

A nurse is preparing to administer furosemide 40 mg IV. Available is furosemide 10 mg/1 mL. How many mL should the nurse administer per dose?

A public health nurse is preparing an educational session at a community health center about the social determinants of health (SDOH). Which of the following information should the nurse include?

A nurse is teaching about delegation with a newly licensed nurse.Which of the following statements if made by the newly licensed nurse indicates understanding?

The nurse is educating a patient with phlebitis of the left leg. What alternative therapy should this patient avoid until the condition is resolved?.

A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take?

A nurse is preparing to administer lidocaine 50 mg IV bolus. Available is lidocaine 200 mg/mL. How many mL should the nurse administer per dose? rounded off to the nearest hundredth

A nurse is reviewing the documentation of a client's blood pressure by a newly licensed nurse.
The documentation states, "Blood pressure 102/58 mm Hg, client sitting up in a chair.”. Which of the following information should the nurse clarify?