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 D

Explanation

The correct answer is choice D. This type of device is useful for a client who cannot assist.

A mechanical lift is used to transfer residents who cannot support their own weight.

It does not require the client to use upper body strength, as choice A suggests.

The lower end of the sling should go under the client’s thighs, not below the calves, as choice B states.

The sides of the sling are not for the client to hold on to, but for the caregiver to attach to the hooks on the lift, as choice C implies.

Therefore, choices A, B and C are wrong because they do not reflect the proper use of a mechanical lift.

A. “You must have advance directives in place in order to refuse recommended treatment.”. B. “An attorney is needed in order for you to name a designee in your health care proxy.”. C. “A living will can be an oral statement that you agree upon with your provider.”. D. “You can decline to have certain medical procedures performed in your living will.”.

Correct Answer is D

Explanation

The correct answer is choice D. A living will can specify which medical procedures a person wants or does not want to receive in certain situations, such as when they are terminally ill or permanently unconscious.

A living will is a type of advance directive, which is a legal document that provides instructions for medical care if a person is unable to make decisions for themselves.

Choice A is wrong because a person does not need to have advance directives in order to refuse recommended treatment.

They have the right to accept or decline any medical intervention at any time, as long as they are competent and able to communicate their wishes.

Choice B is wrong because a person does not need an attorney to name a designee in their health care proxy.

A health care proxy is another type of advance directive that appoints a person to make health care decisions for someone else if they are unable to do so.

A health care proxy can be completed without involving a lawyer, as long as it meets the state’s requirements for a valid document.

Choice C is wrong because a living will cannot be an oral statement that a person agrees upon with their provider.

A living will must be in writing and follow the state’s laws for creating legal documents.

Depending on the state, a living will may need to be signed by a witness or notarized.

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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 showing a newly licensed nurse how to use a mechanical lift. Which of the following statements by the newly licensed nurse indicates an understanding of this assistive device?

Correct Answer is D

Explanation

A nurse is reinforcing information with a client who wishes to complete their advance directives. Which of the following statements should the nurse make?

Correct Answer is D

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?