Nokea
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. Deflate the cuff faster when repeating the BP measurement.
- D. Measure the client's BP in the other arm.
Correct Answer: D
Rationale: Measuring in the other arm verifies the sudden BP increase, ruling out measurement error.
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A nurse is assisting in the care of a client who just started receiving a blood transfusion 5 min ago. Which of the following findings should be reported first to the provider?
- A. Hyperthermia
- B. Urticaria
- C. Dyspnea
- D. Headache
Correct Answer: C
Rationale: Dyspnea is a critical sign of a transfusion reaction, requiring immediate reporting.
A nurse is preparing to administer medications to a client. Which of the following pieces of information should the nurse use as a client identifier?
- A. Photograph
- B. Medical diagnosis
- C. Room number
- D. Age
Correct Answer: A
Rationale: A photograph is a reliable identifier per safety standards.
A nurse is reinforcing teaching with a client about how to collect a stool specimen. Which of the following instructions should the nurse include?
- A. Urinate after the specimen collection.
- B. Place 1.3 cm (0.5 in) of formed stool into a culture tube.
- C. Keep the specimen in a warm area.
- D. Avoid placing toilet tissue in the bedpan after defecation.
Correct Answer: D
Rationale: Avoiding toilet tissue prevents contamination of the stool specimen.
A nurse in a provider's office is collecting data from an older adult client. The client states that he is having difficulty sleeping. Which of the following strategies should the nurse recommend to promote sleep?
- A. Take a 1-hour nap each day.
- B. Drink a glass of milk before bedtime.
- C. Take a long walk before bedtime.
- D. Watch television in bed.
Correct Answer: B
Rationale: Milk contains tryptophan, which promotes sleep.
A nurse is reinforcing teaching with a client who is about to start using a standard walker. Which of the following statements by the client indicates an understanding of the instructions?
- A. I'll keep the height of my walker adjusted so lean slightly forward
- B. I'll slide the walker and move it about a foot in front of me
- C. I'll move the walker and my stronger leg ahead at the same time
- D. I'll keep my elbows slightly bent when I grasp the walker
Correct Answer: D
Rationale: Slightly bent elbows ensure proper posture and control with a walker.