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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 assisting with meal planning for a client who has been prescribed a mechanical soft diet. The nurse should instruct the client to avoid which of the following foods?
- A. Applesauce
- B. Mashed potatoes
- C. Orange slices
- D. Soft bread
Correct Answer: C
Rationale: Orange slices have membranes that are hard to swallow, which can be problematic for clients on a mechanical soft diet.
A nurse in a provider's office is assessing a client who reports a decrease in the effectiveness of their arthritis medication. Which of the following client information should the nurse identify as a contributing factor?
- A. The client has a history of recurring bowel inflammation
- B. The client has recently increased their exercise regimen
- C. The client is taking herbal supplements
- D. The client is experiencing increased stress
Correct Answer: A
Rationale: Recurring bowel inflammation can decrease gastrointestinal motility, affecting the absorption of oral medications.
A nurse is performing a focused assessment for a client who has dysrhythmias. What indicates ineffective cardiac contractions?
- A. Increased blood pressure
- B. Pulse deficit
- C. Normal heart rate
- D. Elevated oxygen saturation
Correct Answer: B
Rationale: A pulse deficit indicates ineffective cardiac contractions and the presence of cardiac dysrhythmias.
A nurse is completing an admission assessment for a client who has hearing loss. What action should the nurse take?
- A. Speak loudly to the client
- B. Use written communication to assist with communication
- C. Avoid eye contact while speaking
- D. Use sign language without an interpreter
Correct Answer: B
Rationale: Using written communication can help ensure that the client understands the information being conveyed.
A nurse is caring for a client who expresses anxiety about an upcoming surgery. What should the nurse do?
- A. Reassure the client that everything will be fine
- B. Ask the client to describe feelings
- C. Tell the client to stay positive
- D. Provide information about the surgery
Correct Answer: B
Rationale: Asking the client to describe their feelings allows the nurse to understand the specific concerns and anxieties the client is experiencing.