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 B

Explanation

This action can help to reduce environmental stressors for clients in an acute care unit by limiting noise, crowding, and potential sources of infection.

Visitors should be allowed according to the client’s preference and condition, but excessive or inappropriate visitors should be discouraged.

Choice A is wrong because offering the clients many choices regarding care can increase their stress and anxiety, especially if they are confused, overwhelmed, or unable to make decisions.

The nurse should respect the client’s autonomy and preferences, but also provide guidance and education to help them make informed choices.

Choice C is wrong because assigning different nurses to provide care for clients each day can reduce the continuity and quality of care, as well as the trust and rapport between the client and the nurse.

The nurse should strive to provide consistent and individualized care for each client and establish a therapeutic relationship.

Choice D is wrong because turning on loud music in client care areas can increase environmental stressors for clients in an acute care unit by creating noise pollution, disrupting sleep, and interfering with communication.

The nurse should maintain a quiet and calm environment for the clients and use music only if it is soothing and requested by the client.

A. Interlock her fingers and hold her hands away from her body above her waist. B. Clasp her hands together in a relaxed position behind her body at her waist. C. Place one hand over the other against the part of the gown covering her upper body. D. Keep her arms at the sides of her body with her hands in a relaxed position.

Correct Answer is A

Explanation

The correct answer is choice A. Interlock her fingers and hold her hands away from her body above her waist.

This is because this position minimizes the risk of contaminating the sterile gloves by touching any non-sterile surfaces or objects.

The nurse should also keep her hands above her waistline to prevent contamination

Choice B is wrong because clasping the hands together behind the body at the waist could contaminate the gloves by touching the non-sterile gown or the skin

Choice C is wrong because placing one hand over the other against the part of the gown covering the upper body could contaminate the gloves by touching the non-sterile gown or the skin

Choice D is wrong because keeping the arms at the sides of the body with the hands in a relaxed position could contaminate the gloves by touching any nonsterile surfaces or objects

Sterile gloves are a type of disposable rubber gloves that are put through specific procedures to eliminate germs and microorganisms.

They are used to prevent and minimize infection during surgeries or invasive procedures

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is assisting in creating a plan to reduce environmental stressors for clients in an acute care unit. Which of the following actions should the nurse include in the plan?

Correct Answer is B

Explanation

A nurse is wearing sterile gloves in preparation for assisting with a client’s sterile procedure. While waiting for the procedure to begin, how should the nurse position her hands?

Correct Answer is A

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?