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A nurse on a medical-surgical unit is collecting data from a client who is postoperative following abdominal surgery. The client's BP was 126/72 mm Hg 15 min ago. The nurse now finds that the client's BP is 176/96 mm Hg. Which of the following actions should the nurse take?
- A. Use a narrower cuff to repeat the BP measurement.
- B. Request a prescription for an antihypertensive medication.
- C. Measure the client's BP in the other arm.
- D. Deflate the cuff faster when repeating the BP measurement.
Correct Answer: C
Rationale: Measuring in the other arm confirms accuracy of the elevated reading.
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A nurse is caring for a young adult client who is postoperative and requires physical therapy, pain management, and dietary advancement. The nurse enters the client's room and finds them dressing and stating that they are going home. Which of the following actions should the nurse take?
- A. Administer a sedative medication to the client.
- B. Explain to the client that they cannot leave until the surgeon discharges them.
- C. Have the client sign an against medical advice form.
- D. Tell the client that the surgeon will prescribe restraints if they try to leave.
Correct Answer: C
Rationale: Signing an AMA form documents the client's informed decision to leave against advice.
A nurse is caring for a client who is receiving detoxification treatment for an opioid use disorder. As the nurse is preparing to administer a methadone IM injection, the client tells the nurse, 'I am afraid of needles.' Which of the following actions should the nurse take?
- A. Remind the client that they must receive the medication as prescribed.
- B. Tell the client not to worry because the pain will be temporary.
- C. Request a change in the medication route to PO.
- D. Ask one of the client's loved ones to encourage them to receive the IM medication.
Correct Answer: C
Rationale: Requesting a PO route addresses the client’s fear while ensuring treatment.
A nurse is collecting data from a client who reports feeling short of breath and notes that the client's SaO2 level is 88% while on room air. Which of the following actions should the nurse take first?
- A. Check the client's medical records to see which medications were recently administered.
- B. Review the client's most recent SaO2 level in the medical record.
- C. Notify the charge nurse of the client's condition.
- D. Recheck the client's SaO2 level after having the client cough and clear their throat.
Correct Answer: D
Rationale: Rechecking after coughing assesses if the low SaO2 is due to mucus, addressing it immediately.
A nurse at a long-term care facility is reinforcing teaching with a newly licensed nurse about the proper use of restraints. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
- A. Pad bony prominences before applying a restraint.
- B. Tie the ends of the restraint to the client's bed rail.
- C. Use a square knot to secure the client's restraint to the bed.
- D. Observe the client's skin integrity every 2 hr.
- E. Ensure that 2 fingers can be placed between the restraint and the client.
Correct Answer: A,D,E
Rationale: A: Protects skin. D: Monitors for issues. E: Prevents overly tight restraints.
A nurse is reinforcing discharge teaching about fecal occult blood testing with a client. Which of the following instructions should the nurse include in the teaching?
- A. Place a thick layer of stool on the specimen card.
- B. Urinate prior to collecting the stool specimen.
- C. Discontinue supplements containing vitamin C 24 hours before the test.
- D. Refrain from consuming pork 7 days before the test.
Correct Answer: C
Rationale: Vitamin C can cause false negatives, so discontinuing it ensures accuracy.