The nurse observes a decrease in a client's level of consciousness. Which vital sign should the nurse obtain first?

Blood pressure.

Temperature.

Respiratory rate.

Pulse rate.

Answer and Explanation

The Correct Answer is C

Choice A: Blood pressure is not the first vital sign to obtain because it is not as sensitive to changes in the level of consciousness as respiratory rate. Blood pressure may be normal or elevated in some cases of decreased consciousness, such as stroke or head injury.

Choice B: Temperature is not the first vital sign to obtain because it is not as relevant to the level of consciousness as respiratory rate. Temperature may be normal or slightly elevated in some cases of decreased consciousness, such as infection or dehydration.

Choice C: Respiratory rate is the first vital sign to obtain because it reflects the adequacy of oxygenation and ventilation, which are essential for brain function. Respiratory rate may be increased, decreased, or irregular in cases of decreased consciousness, depending on the cause and severity.

Choice D: Pulse rate is not the first vital sign to obtain because it is not as indicative of the level of consciousness as respiratory rate. Pulse rate may be normal, fast, or slow in cases of decreased consciousness, depending on the cause and compensatory mechanisms.

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Correct Answer is D

Explanation

Choice A Reason: Massaging the injection site can cause bruising and bleeding, and is not recommended for subcutaneous heparin injections.

Choice B Reason: Rotating injections between different body sites can increase the risk of hematoma formation and skin irritation, and is not advised for subcutaneous heparin injections.

Choice C Reason: Expelling the air in the prefilled syringe can result in a loss of medication dose, and is not necessary for subcutaneous heparin injections.

Choice D Reason: Injecting in the abdominal area at least 2 inches from the umbilicus is the correct technique for subcutaneous heparin injections, as it reduces the risk of injury to blood vessels and nerves, and ensures consistent absorption of the medication.

A. One ounce medicine cup. B. 3 mL syringe and a sterile needle. C. 3 mL syringe. D. Tuberculin syringe.

Correct Answer is C

Explanation

Choice A Reason: This is incorrect because a one ounce medicine cup is not precise enough to measure a 5 mL dose of viscous liquid solution. A one ounce medicine cup can hold about 30 mL of liquid, which is too large for a small dose.

Choice B Reason: This is incorrect because a 3 mL syringe and a sterile needle is not appropriate for oral administration of medication. A needle may cause injury to the oral mucosa or the esophagus.

Choice C Reason: This is correct because a 3 mL syringe can measure a 5 mL dose of viscous liquid solution accurately and safely. A syringe can draw up the solution easily and deliver it to the mouth without spilling or dripping.

Choice D Reason: This is incorrect because a tuberculin syringe is too small to measure a 5 mL dose of viscous liquid solution. A tuberculin syringe can hold only 1 mL of liquid, which is not enough for the required dose.

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The nurse observes a decrease in a client's level of consciousness. Which vital sign should the nurse obtain first?

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Naxlex Comprehensive Predictor Exams

The nurse is teaching a client how to self-administer low-molecular-weight heparin subcutaneously. Which instruction should the nurse include?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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