The nurse measures the client’s blood pressure (BP) and notes that it is significantly higher than the previous reading. Which should the nurse do next? (Select all that apply)

Immediately take 2 more readings on the same arm.

Assign the unlicensed assistive personnel (UAP) to recheck the BP in an hour.

Retake the client’s blood pressure in the opposite arm.

Ask another nurse to assist in assessing for an apical-radial pulse deficit.

Determine the client’s activity and feelings prior to the BP measurement.

Answer and Explanation

Correct Answer : A,C,E

Choice A reason: Taking two more readings confirms elevated BP, as a single reading may reflect technique errors or transient factors like pain, which increase sympathetic activity and vasoconstriction. Multiple readings ensure accuracy, critical for diagnosing hypertension and guiding intervention to prevent cardiovascular complications like stroke.

Choice B reason: Assigning a UAP to recheck BP in an hour delays assessment of potentially dangerous hypertension, which risks acute complications like myocardial ischemia. Immediate confirmation is needed, as elevated BP from norepinephrine release increases vascular resistance, making delayed rechecking inappropriate for urgent evaluation.

Choice C reason: Retaking BP in the opposite arm verifies accuracy, as differences may indicate arterial occlusion. Elevated BP increases catecholamine-driven vascular resistance. Measuring both arms rules out localized issues, ensuring reliable data to guide management of hypertension, critical to prevent end-organ damage like renal failure.

Choice D reason: Assessing apical-radial pulse deficit is relevant for atrial fibrillation, not directly for elevated BP. Hypertension results from increased vascular resistance, not pulse discrepancies. Confirming BP and assessing context are more immediate to determine urgency, making this less relevant than verifying readings or identifying triggers.

Choice E reason: Determining activity and feelings identifies transient BP elevation causes, like stress or exercise, which raise norepinephrine, increasing heart rate and vascular tone. This contextualizes the reading, differentiating situational from chronic hypertension, ensuring appropriate intervention to manage cardiovascular risk and guide further assessment.

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Correct Answer is D

Explanation

Choice A reason: Acetaminophen reduces pain but is secondary to preventing infection and bleeding with petrolatum dressings. Dressings are the immediate post-circumcision priority to protect the surgical site, per circumcision care and infection control protocols in neonatal nursing practice.

Choice B reason: Wrapping in blankets maintains warmth but does not address the surgical site’s immediate needs. Petrolatum dressings prevent infection and adhesion, critical post-circumcision. Warmth is secondary, per circumcision care and neonatal thermoregulation standards in nursing practice.

Choice C reason: Offering a glucose-dipped pacifier soothes but does not protect the circumcision site from infection or bleeding. Petrolatum dressings are the priority to ensure healing and comfort, per circumcision care and postoperative pain management standards in neonatal nursing practice.

Choice D reason: Applying petrolatum gauze dressings prevents infection, promotes healing, and reduces adhesion of the circumcision site to diapers. This is the priority intervention to protect the surgical wound, per evidence-based circumcision care and infection control protocols in neonatal nursing practice.

A. Remind the client to keep light pressure on the abdomen and cough after fully exhaling. B. Confirm that the breathing technique was correct but hand pressure is not necessary. C. Document that the client successfully demonstrated the diaphragmatic breathing technique. D. Demonstrate how to expand the abdomen while inhaling and let it relax while exhaling.

Correct Answer is D

Explanation

Choice A reason: Keeping pressure on the abdomen and coughing is incorrect for diaphragmatic breathing, which enhances lung expansion, not airway clearance. Coughing is for post-drainage. The client’s incorrect technique (abdominal expansion on exhalation) requires correction, as this reverses mechanics, reducing ventilation efficiency in conditions like COPD.

Choice B reason: The client’s technique is incorrect, expanding the abdomen on exhalation, not inhalation, reducing diaphragmatic efficacy. Confirming it as correct is wrong, as it impairs lung expansion. Demonstrating proper technique corrects the error, ensuring effective breathing to improve oxygenation, addressing the physiological need for ventilation.

Choice C reason: Documenting success is inaccurate, as the client’s technique is reversed, expanding the abdomen on exhalation. Diaphragmatic breathing requires inhalation expansion to lower the diaphragm, increasing lung capacity. Correcting the technique via demonstration ensures proper mechanics, not documenting an ineffective method that hinders ventilation.

Choice D reason: Demonstrating proper diaphragmatic breathing corrects the client’s error of exhalation expansion. Inhaling expands the abdomen via diaphragmatic descent, increasing tidal volume; exhaling relaxes it. This optimizes ventilation, addressing the need for effective breathing in conditions requiring enhanced lung function, ensuring the client learns the correct technique.

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The nurse measures the client’s blood pressure (BP) and notes that it is significantly higher than the previous reading. Which should the nurse do next? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The parents of a male infant newborn have signed an informed consent for circumcision. Which priority intervention should the nurse implement upon completion of the circumcision procedure?

Correct Answer is D

Explanation

The nurse observes an adult client perform a return demonstration of diaphragmatic breathing. The client inhales while holding the abdomen, then removes the hand to allow expansion of the abdomen during exhalation. Which action should the nurse take after observing the client’s demonstration?

Correct Answer is D

Explanation

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