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A nurse receives a report from an assistive personnel that a client's BP is 160/95. What should the nurse do first?
- A. Notify the healthcare provider
- B. Recheck the client's BP
- C. Document the findings
- D. Administer antihypertensive medication
Correct Answer: B
Rationale: The nurse should first reassess the client's BP to confirm the reading before taking any further action.
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A nurse is planning to administer several medications to a client through an NG tube. Which actions should the nurse take?
- A. Dissolve crushed tablet medications in tap water
- B. Use 30-40 mL of sterile water for each medication
- C. Dissolve crushed tablet medications in sterile water
- D. Administer medications without dissolving
Correct Answer: C
Rationale: Crushed tablet medications should be dissolved in 15-30 mL of sterile water to ensure proper delivery through the NG tube.
A nurse is providing discharge teaching to a client who has a prescription for home oxygen. Which information should the nurse teach?
- A. Use a humidifier with the oxygen
- B. Wear cotton socks when the oxygen is in use
- C. Avoid all types of smoking materials
- D. Use a nasal cannula during meals
Correct Answer: B
Rationale: Wearing cotton socks helps prevent static electricity, which poses a fire risk when using oxygen.
A nurse is performing a cultural assessment of a group of clients to maintain respect for their value systems and beliefs. Which of the following should the nurse identify as examples of cultural variables?
- A. Eye contact
- B. Personal space
- C. Touch
- D. All of the above
Correct Answer: D
Rationale: Eye contact, personal space, and touch are cultural variables that can affect communication.
A nurse is teaching about safety risks for adolescents. What should be included?
- A. Adolescents are more likely to follow rules
- B. Peer influence to participate in high-risk behaviors can lead to injury
- C. Most injuries occur during sports activities
- D. Adolescents are aware of the dangers of substance use
Correct Answer: B
Rationale: Peer influence during adolescence can lead to increased participation in high-risk behaviors, resulting in potential injuries.
A nurse is caring for a client who has an indwelling urinary catheter. What should the nurse identify as a sign of catheter occlusion?
- A. Bladder distention
- B. Frequent urination
- C. Dark urine
- D. Increased thirst
Correct Answer: A
Rationale: Bladder distention indicates the inability to empty the bladder, which can be a sign of catheter occlusion.