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. Placing a pillow under the client’s flexed leg is part of the Sims’ position, which is a way of lying on the left side, with the right hip and knee bent and the left arm behind the back.

It is used for vaginal and colonic examinations and natural childbirth.

Choice A is wrong because positioning the client’s arms at his sides is not part of the Sims’ position.

The left arm should be behind the back.

Choice B is wrong because elevating the client’s feet with two pillows is not part of the Sims’ position.

The lower leg should be straightened and the upper leg should be bent.

Choice C is wrong because raising the head of the client’s bed to a 30° angle is not part of the Sims’ position.

The bed should be flat or slightly tilted.

A. Measure the intake and output of a client who has received furosemide. B. Check a client’s peripheral IV site for redness or swelling. C. Assess the pain level of a client who has received acetaminophen. D. Reinforcing teaching with a client about crutch-gait walking E. None F. None

Correct Answer is C

Explanation

- When coordinating the care of a group of clients with assistive personnel (AP), it's important to delegate tasks appropriately based on the AP's scope of practice and training. Here are the tasks that can be assigned to the AP:

Measure the intake and output of a client who has received furosemide: This task involves recording fluid intake and output, which is typically within the scope of practice for an AP, as long as they have been trained in the proper procedure and documentation.

Check a client’s peripheral IV site for redness or swelling: This task involves basic assessment and can be assigned to an AP, as long as they are familiar with the signs of potential complications related to IV sites and have been trained in the facility's protocol for reporting any issues.

Reinforcing teaching with a client about crutch-gait walking: Education and reinforcement of information provided by healthcare professionals can often be delegated to APs, especially if they have received training on the specific topic. However, it's important to ensure that the AP is knowledgeable about crutch-gait walking and the information they are reinforcing.

The task related to assessing pain (e.g., assessing the pain level of a client who has received acetaminophen) should generally be performed by a licensed healthcare provider, such as a nurse. Assessment of pain requires a deeper understanding of the client's pain experience and may involve making clinical decisions related to pain management.

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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 planning to place a client into the Sims’ position. Which of the following actions should the nurse plan to take?

Correct Answer is D

Explanation

A nurse is coordinating the care of a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse not assign to the AP?

Correct Answer is C

Explanation

A nurse is preparing to administer a medication from an ampule. Which of the following is an appropriate action for the nurse to take?

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A nurse is reviewing the laboratory results for a client who reports vomiting and diarrhea for 2 days. Which of the following laboratory findings should the nurse expect?

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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?