The nurse identifies that the patient care tech recorded the client's blood pressure as 78/52. The nurse recognizes this blood pressure is abnormally low for this client. What is the best response by the nurse?

Reassess the blood pressure measurement.

Notify the provider.

Recheck the blood pressure measurement in 30 minutes.

Have the patient care tech take the blood pressure measurement again.

Answer and Explanation

The Correct Answer is A

A. Reassessing the blood pressure measurement is correct because the nurse should always verify abnormal findings before taking further action. The initial reading could be due to equipment error, improper cuff size, or patient positioning.
B. Notifying the provider is incorrect at this time because the nurse should first confirm the accuracy of the reading before escalating concerns.
C. Rechecking the BP in 30 minutes is incorrect because if the reading is accurate, waiting 30 minutes could delay necessary interventions.
D. Having the patient care tech take the BP again is incorrect because the nurse should personally validate the abnormal finding rather than delegating it.

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Correct Answer is C

Explanation

A. Drinking fluids before and after meals but not during meals is incorrect. Clients with dysphagia may require thickened liquids and should sip fluids as needed to facilitate swallowing.
B. Sitting with the head of the bed at a 45-degree angle is incorrect. Clients with dysphagia should be positioned at a 90-degree angle (fully upright) during meals to reduce the risk of aspiration.
C. Thoroughly chewing small amounts of food with each mouthful is correct. Clients with dysphagia should eat slowly, take small bites, and chew food thoroughly to prevent choking and aspiration.
D. Temporomandibular joint pain is not a common issue associated with dysphagia following a stroke. The primary concern is the risk of aspiration.

A. "The documentation satisfies legal standards established by health care organizations and institutions." B. "Documentation of the initial assessment becomes the foundation for the entire nursing process." C. "Incorrect conclusions may be made without the documentation of the nurse's opinions." D. "Health care institutions have established policies regarding documentation of initial assessments."

Correct Answer is B

Explanation

A. While documentation does satisfy legal standards, the primary reason for documenting the initial assessment is to guide the entire nursing process.
B. "Documentation of the initial assessment becomes the foundation for the entire nursing process" is correct because all subsequent care planning, interventions, and evaluations depend on accurate initial assessment data.
C. Documentation should be objective, not based on the nurse’s opinions.
D. Institutional policies are important, but the significance of initial assessment documentation lies in its role in guiding patient care.

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The nurse identifies that the patient care tech recorded the client's blood pressure as 78/52. The nurse recognizes this blood pressure is abnormally low for this client. What is the best response by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing health education to an elderly client with dysphagia following a recent ischemic stroke. What would be most appropriate for the nurse to include in the education?

Correct Answer is C

Explanation

Which of the following statements indicate that the student nurse understands the importance of documenting the initial assessment data?

Correct Answer is B

Explanation

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