The home health nurse is instructing a caregiver about caring for a patient with hypothermia. The nurse recognizes that further instruction when the caregiver states, "I will

instruct the patient to remain on strict bed rest

provide the patient with additional blankets"

encourage the patent to increase his muscle activity”

offer fluids to the patient if permitted

Answer and Explanation

The Correct Answer is C

A.   Keeping the patient on bed rest is appropriate as it conserves energy and helps prevent further heat loss.
B.   Providing additional blankets is a correct intervention to warm the patient gradually.
C.   Increasing muscle activity is contraindicated because it could cause vasoconstriction and worsen hypothermia, as the body focuses on preserving core temperature.
D.   Offering fluids (if permitted) is correct as hydration can help restore normal body temperature regulation.

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Correct Answer is C

Explanation

A. The brachial artery should be at heart level, not waist level, to ensure accurate blood pressure readings.
B. While chatting with the patient may help reduce anxiety, it is not directly related to positioning for accurate blood pressure measurement.
C. Having the patient place their feet flat on the floor ensures proper positioning and helps prevent any interference with blood pressure readings.
D. The arm should be at heart level, not at the shoulder, for accurate readings.

A. Wait 30 minutes and take the pressures again. B. Record both pressures in the medical record. C. Retake the pressure on both arms. D. Retake the pressure on the left arm.

Correct Answer is C

Explanation

A. Waiting 30 minutes is unnecessary unless there is concern about an acute change in the patient's condition.
B. While both readings can be recorded, the difference between arms should be noted, as it can indicate underlying issues such as vascular problems.

C. It is important to retake the blood pressure on both arms to verify accuracy and check for any significant discrepancy.
D. Retaking the pressure on just one arm may miss important information about the other arm's readings.

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The home health nurse is instructing a caregiver about caring for a patient with hypothermia. The nurse recognizes that further instruction when the caregiver states, "I will

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse taking a blood pressure should:

Correct Answer is C

Explanation

If a patient's blood pressure measures 146/92 on the left arm and 138/84 on the right arm, what would you do?

Correct Answer is C

Explanation

During a health interview, an older adult patient has difficulty remembering information about the health history. In order to get the information more reliably, the nurse should:

Older adult patients with hypertension may have an auscultatory gap in their Korotkoff sounds. It is important when taking their blood pressure measurement to:

If dehydration occurs, the blood pressure will

A nurse is caring for a patient with a cardiac disease history. When measuring vital signs, the nurse finds that the radial pulse is 102 beats/min and irregular. The nurse correctly:

A 16-year-old patient sustained a head injury while playing soccer. When performing a neurologic check, the nurse looks at each pupil to determine

The nurse documents vital signs on a newly admitted patient as: "blood pressure is 170/90 mm Hg, the pulse is 80 beats/min, and the respirations are 16 breaths/min." The nurse would record the pulse pressure as:

The normal pattern of breathing is described as

The nurse anticipates that if the stroke volume of a patient is reduced, the pulse will be: