A nurse on a medical-surgical unit is collecting data from a client who is postoperative following abdominal surgery.
The client’s BP was 126/72 mm Hg 15 min ago. The nurse now finds that the client’s BP is 176/96 mm Hg. Which of the following actions should the nurse take?

Deflate the cuff faster when repeating the BP measurement.

Request a prescription for an antihypertensive medication.

Use a narrower cuff to repeat the BP measurement.

Measure the client’s BP in the other arm.

Answer and Explanation

The Correct Answer is D

It's common practice to check blood pressure in both arms when there is a significant discrepancy in blood pressure readings between the arms. This discrepancy could be due to factors like arterial blockages or other conditions. By measuring the blood pressure in the other arm, the nurse can confirm whether the high blood pressure is consistent on both sides or if there was an issue with the initial measurement. This step helps provide a more accurate assessment of the client's blood pressure.

- The other options are not appropriate at this stage:

Deflating the cuff faster may not resolve the issue and could lead to inaccurate measurements.

Requesting a prescription for an antihypertensive medication should only be done after confirming the blood pressure is consistently elevated and under the direction of a healthcare provider.

Using a narrower cuff is not indicated in this situation. It's more important to assess the other arm's blood pressure to identify any discrepancies.

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Correct Answer is C

Explanation

The correct answer is choice C. “I will assist you in any way I can during this process.” This response shows sensitivity and respect for the client’s family and their cultural or religious beliefs. Postmortem care involves caring for a deceased patient’s body with dignity and in a manner that is consistent with the patient’s and family’s wishes.The nurse should offer to assist the family in performing the postmortem care if they request to do so.

Choice A is wrong because the family does not need to sign a release form to perform the postmortem care themselves.

There is no legal requirement for this.

Choice B is wrong because a licensed health care worker does not have to perform postmortem care.

The family can perform the care themselves if they wish, with or without the assistance of a health care worker.

Choice D is wrong because postmortem care takes place before the client leaves the facility, not after.

Postmortem care should be provided as soon as possible to prevent tissue damage or disfigurement.

A. Separate the labia with the nondominant hand. B. Clean around the urinary meatus from front to back. C. Insert the catheter into the urethral meatus. D. Inflate the catheter balloon. E. Secure the catheter to the client’s thigh.

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

No explanation

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A nurse on a medical-surgical unit is collecting data from a client who is postoperative following abdominal surgery. The client’s BP was 126/72 mm Hg 15 min ago. The nurse now finds that the client’s BP is 176/96 mm Hg. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an acute care center is caring for a client who just died. The client’s family requests to perform the postmortem care. Which of the following is an appropriate response for the nurse to make?

Correct Answer is C

Explanation

A nurse is inserting an indwelling urinary catheter for a female client. In which order should the nurse perform the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.).

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

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A nurse on a medical-surgical unit is collecting data from a client who is postoperative following abdominal surgery.
The client’s BP was 126/72 mm Hg 15 min ago. The nurse now finds that the client’s BP is 176/96 mm Hg. Which of the following actions should the nurse take?