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: Withholding the dose delays glucose control, risking hyperglycemia. Obtaining regular insulin ensures accurate dosing, as 70/30 cannot be separated. Timely administration is critical, per diabetes management and insulin therapy protocols in nursing practice for glycemic control.

Choice B reason: Withdrawing regular insulin from a 70/30 vial is impossible, as it’s a fixed mixture. Obtaining a regular insulin vial ensures precise 10-unit dosing, preventing errors, per medication safety and insulin administration standards in diabetes nursing care.

Choice C reason: Pulling 30 units of 70/30 and giving one third is unsafe, as it delivers mixed insulins, not just regular insulin. Obtaining regular insulin ensures accurate dosing, per insulin therapy and patient safety protocols in diabetes management nursing practice.

Choice D reason: Obtaining a new vial of regular insulin ensures the precise 10-unit dose, as 70/30 is a fixed mixture unsuitable for separating regular insulin. This prevents dosing errors, per evidence-based insulin administration and medication safety standards in diabetes nursing care.

A. Abdominal girth. B. Bowel sounds. C. Vital signs. D. Breath sounds.

Correct Answer is C

Explanation

Choice A reason: Measuring abdominal girth monitors distention but is less critical before digital removal of a fecal impaction. Impaction causes constipation, but girth changes are slow. Vital signs detect autonomic responses like bradycardia from vagal stimulation during the procedure, making them more urgent to ensure safety.

Choice B reason: Bowel sounds indicate motility, reduced in impaction, but do not predict complications during digital removal, which risks vagal stimulation causing bradycardia. Vital signs are critical, detecting cardiovascular instability, ensuring safety during this invasive procedure, making bowel sounds less immediate for assessment.

Choice C reason: Assessing vital signs is essential, as digital removal stimulates rectal nerves, potentially triggering a vagal response, causing bradycardia or hypotension. This risks syncope or shock. Monitoring heart rate and blood pressure ensures cardiovascular stability, preventing complications during this procedure, addressing autonomic risks effectively.

Choice D reason: Breath sounds assess respiratory status, unrelated to fecal impaction removal, a gastrointestinal issue. The procedure risks vagal stimulation, not pulmonary effects. Vital signs detect cardiovascular changes like bradycardia, ensuring safety during rectal manipulation, making breath sounds irrelevant for this assessment.

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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

Based on the capillary glucose measurement, a client is to receive 10 units of regular insulin. The client’s medication drawer contains one vial of a 70/30 mixture of regular insulin and isophane insulin. How should the nurse prepare the prescribed dose?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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