A nurse just received a client from the emergency department, who presents to the floor with a history of stroke. He is admitted with left-sided weakness. His vital signs are to be monitored every 4 hours. On initial assessment at 0800 the client's blood pressure was noted to be 150/100. What priority action should the nurse do next?

Check the patient's pulse and temperature.

Have the UAP repeat the blood pressure.

Repeat the blood pressure.

Administer the patient’s morning medications.

Answer and Explanation

The Correct Answer is C

A reason:

Checking the patient's pulse and temperature is important but not the priority. The elevated blood pressure needs to be reassessed first to confirm accuracy before taking further actions.

B reason:

Having the UAP repeat the blood pressure is not appropriate. The nurse should personally repeat the measurement to ensure accuracy and assess for any potential issues immediately.

C reason:

Repeating the blood pressure is the priority. An initial high reading needs to be confirmed to rule out any measurement error and to determine if immediate intervention is needed.

D reason:

Administering the patient's morning medications may be necessary, but confirming the blood pressure reading is more urgent to ensure that any medications given are appropriate for the current condition.

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Correct Answer is D

Explanation

A reason:

Troponin levels are not directly related to malnutrition. Troponin is a cardiac biomarker used to diagnose myocardial infarction (heart attack) and other heart-related conditions.

B reason:

Total bilirubin is primarily used to assess liver function and diagnose conditions like jaundice and liver disease. It is not specifically related to nutritional status.

C reason:

Creatine kinase is an enzyme found in the heart, brain, and skeletal muscle. Elevated levels can indicate muscle damage but are not directly associated with malnutrition.

D reason:

Albumin is a protein made by the liver, and its levels can be significantly affected by malnutrition. Low albumin levels are often seen in individuals with poor nutritional status, as adequate protein intake is essential for maintaining normal albumin levels.

A. Airborne B. Protective C. Contact D. Droplet

Correct Answer is C

Explanation

A reason:

Airborne precautions are not required for VRE. These precautions are used for infections transmitted through the air, such as tuberculosis, which is not the case with VRE.

B reason:

Protective precautions (also known as neutropenic or reverse precautions) are used to protect immunocompromised patients from infections. They are not appropriate for preventing the spread of VRE.

C reason:

Contact precautions are correct. VRE is typically transmitted through direct or indirect contact with contaminated surfaces or infected body fluids. Contact precautions help prevent the spread of VRE to other patients and healthcare workers.

D reason:

Droplet precautions are used for infections transmitted through respiratory droplets, such as influenza. VRE is not transmitted in this manner, so droplet precautions are not necessary.

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Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who reports anorexia and is experiencing malnutrition. Which of the following laboratory findings should the nurse expect to be altered?

Correct Answer is D

Explanation

A nurse is admitting a client who has a wound infected with vancomycin-resistant enterococci (VRE). Which of the following types of precautions should the nurse plan to initiate?

Correct Answer is C

Explanation

A nurse is assessing a client who is 48 hours postoperative following knee surgery. Which of the following findings should the nurse report to the provider?

A nurse is teaching an older adult client who has left-sided weakness about cane use. Which of the following instructions should the nurse include?

The nurse is preparing to change the linens on the bed of a client who has a draining sacral wound infected by MRSA. Which PPE items should the nurse plan to use? (Select all that apply.)

A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?

A client receives an oral pain medication. In 1 hour the nurse should:

A nurse is completing an 8-hour I&O record for a client who consumed 4 oz juice, 6 oz tea, a 100 mL cup full of ice chips, an IV bolus of 150 mL, and 8 oz broth. The nurse should record how many mL of intake on the client's record?

A nurse is assessing a client who has a heart rate of 115. Which of the following is the medical term?

A nurse is developing a plan of care for a client who has a stage 3 pressure ulcer. Which of the following interventions should the nurse include in the plan?