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Which of the following actions should the nurse take?
- A. Use the palpatory method to determine blood pressure
- B. Place the arm above the level of the client's heart.
- C. Apply the largest cuff available.
- D. Deflate the cuff quickly.
Correct Answer: A
Rationale: The palpatory method can help obtain a more accurate reading when sounds are difficult to auscultate.
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A nurse on a medical-surgical unit is notified that a mass casualty event has occurred in the community. Which of the following actions should the nurse plan to take?
- A. Act as a liaison between the facility and the media:
- B. Recommend to the provider specific acute care clients for discharge.
- C. Determine the medical needs of incoming clients through the emergency department
- D. Call in additional medical surgical unit nursing care staff.
Correct Answer: C
Rationale: Correct Answer: C
Rationale: The nurse should plan to determine the medical needs of incoming clients through the emergency department during a mass casualty event to prioritize care based on severity. This action allows for efficient allocation of resources and timely treatment for those in critical condition. Acting as a liaison with the media (A) is not a priority during such emergencies. Recommending clients for discharge (B) is inappropriate as the focus should be on incoming patients. Calling in additional staff (D) may be necessary but determining medical needs is the immediate priority.
Which of the following actions should the nurse take?
- A. Encourage the client to watch television
- B. Administer a dose of atomoxetine to decrease anxiety
- C. Teach the client how to meditate
- D. Sit with the client to provide a sense of security.
Correct Answer: D
Rationale: Providing a calming presence can help de-escalate panic symptoms.
Which of the following information provided by the client indicates improvement? Select all that apply.
- A. The client reports frequent toothaches and lack of dental care
- B. The client makes eye contact and smiles when speaking.
- C. The client's adult child prepares two muss per day for the client.
- D. The client's clothing is clean and appropriate for the weather.
- E. The client has gained 1.11 kg 14 ibL BMI is 18.9
- F. The client receives three baths per week from a home care aide.
Correct Answer: B,C,D,E,F
Rationale: Improvement signs encompass hygiene, nutrition, weight gain, and social interaction.
A nurse is providing teaching to a client who has a new prescription for enoxaparin. Which of the following medications for pain relief should the nurse include in the teaching that can be taken concurrently with enoxaparin?
- A. Ibuprofen
- B. Naproxen sodium
- C. Acetaminophen
- D. Aspirin
Correct Answer: C
Rationale: Rationale: Acetaminophen is the appropriate pain relief option to be taken concurrently with enoxaparin because it does not interfere with platelet aggregation or clotting factors, unlike other options. Ibuprofen, naproxen sodium, and aspirin are nonsteroidal anti-inflammatory drugs (NSAIDs) which can increase the risk of bleeding when taken with enoxaparin. Acetaminophen, on the other hand, does not have the same effect on platelet function, making it a safer choice for pain relief in patients taking enoxaparin.
Which of the following manifestations should the nurse expect?
- A. Shortness of breath
- B. Dizziness
- C. Epistaxis
- D. Headache
Correct Answer: B
Rationale: Dizziness reflects reduced circulating volume.