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The nurse is obtaining a systolic blood pressure by palpation. While inflating the cuff, the radial pulse is no longer palpable at 90 mm Hg. Which action should the nurse take?
- A. Record a palpable systolic pressure of 90 mm Hg.
- B. Release the manometer valve immediately.
- C. Document the absence of the radial pulse.
- D. Inflate the blood pressure cuff to 120 mm Hg.
Correct Answer: D
Rationale: Inflate above pulse disappearance for accuracy.
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The palliative care nurse receives a consult for a terminally ill client in the intensive care unit. The client is weak, mouth breathing, and refusing anything to eat or drink. Which intervention should the nurse include in the plan of care?
- A. Record the client’s daily weight.
- B. Maintain in high Fowler’s position.
- C. Keep mucous membranes moist.
- D. Report any change in urine color.
Correct Answer: C
Rationale: Moist membranes enhance comfort.
The healthcare provider prescribes a 24-hour urine specimen to be collected for creatinine clearance. The client is eager to go home and tells the nurse that the first sample was put in the urinal 2 hours ago. Which action should the nurse implement?
- A. Begin the collection the next day.
- B. Empty the sample into the 24-hour container.
- C. Observe the sample for sediment.
- D. Start collecting the specimen with the next void.
Correct Answer: D
Rationale: First void is discarded for accuracy.
Which intervention is most important for the nurse to implement before leaving a postoperative client with severe obstructive sleep apnea (OSA) alone?
- A. Remove dentures or other oral appliance.
- B. Elevate the head of the bed to a 45-degree angle.
- C. Apply the client’s positive airway pressure device.
- D. Put and lock the side rails in place.
Correct Answer: C
Rationale: CPAP prevents airway collapse.
The client had a large, loose stool.
Vital signs: Temperature 98.7°F (37°C) orally. Heart rate 73 beats/minute.
Blood pressure 144/82 mm Hg. The client had a large, loose stool. The client had a large, loose stool.
Place the client on contact precautions.
Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take, and two parameters to assess the client’s progress.
- A. Collect stool for culture, Start a high-fiber diet., Administer an oral steroid.,Make the client NPO
- B. Secretory diarrhea.Steatorrhea,Motility diarrhea,Osmotic diarrhea
- C. Heart rate, Serum potassium,Respiratory rate, Urine sodium
Correct Answer:
Rationale: Secretory diarrhea fits; stool culture and NPO address infection; heart rate and potassium monitor dehydration.
A 64-year-old female client with a 3-day history of cough and chest pain is admitted for presumed pneumonia. The client has a history of type 2 diabetes mellitus and takes insulin glargine 17 units in the morning and 17 units in the evening. Which of the following actions should the nurse take to prevent medication errors?
- A. Double check all dosage calculations.
- B. nusually large or small doses.
- C. Compare the medication label to the order.
- D. Use at least 2 client identifiers before administering a dose.
- E. Involve and educate clients in medication administration.
- F. Document all medication in the electronic record as soon as it is given.
Correct Answer: A,C,D,E.F
Rationale: Verification and documentation ensure safety.