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 A

Explanation

The correct answer is choice A: "I will speak with your provider on your behalf."

Choice A rationale: The principle of advocacy in nursing involves supporting and speaking up for clients to ensure their rights, needs, and preferences are respected. By offering to speak with the provider on the client's behalf, the nurse demonstrates advocacy by actively working to represent the client's interests and facilitate communication between the client and the health care team.

Choice B rationale: While promising to fulfill commitments is an aspect of maintaining professional integrity, it does not directly demonstrate advocacy. Advocacy is more about actively supporting the client's rights and needs rather than personal dedication to fulfilling promises.

Choice C rationale: Maintaining the privacy and confidentiality of client information is essential in nursing practice, but it is not specifically related to advocacy. Privacy is a separate ethical principle that focuses on protecting the client's personal information and upholding their right to privacy.

Choice D rationale: Encouraging clients to make decisions about their health care is important for promoting autonomy. However, advocacy involves actively supporting the client's decisions and ensuring their rights are respected, rather than simply allowing them to make decisions.

A. “The device requires the client to use upper body strength.”. B. “The lower end of the sling goes below the client’s calves.” C. “The sides of the sling are for the client to hold on to.”. D. “This type of device is useful for a client who cannot assist.”.

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.

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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 is assisting with the admission of a client. Which of the following statements should the nurse make to demonstrate the principle of advocacy?

Correct Answer is A

Explanation

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

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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?