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When taking Mr. D's blood pressure, the first sound you hear is at 162, and the second sound you hear is at 86. You should document and report that the blood pressure is _____________.
- A. 86/162
- B. irregular and high
- C. 162/86
- D. normal for people of all ages
Correct Answer: C
Rationale: The correct answer is C: 162/86. The first sound heard corresponds to the systolic pressure (top number) and the second sound heard corresponds to the diastolic pressure (bottom number). Therefore, the blood pressure is documented as systolic/diastolic. In this case, the first sound at 162 indicates the systolic pressure, and the second sound at 86 indicates the diastolic pressure. Alternatives A (86/162) is incorrect as systolic pressure always comes first. B (irregular and high) is incorrect as the blood pressure values are within normal range. Option D (normal for people of all ages) is incorrect because the blood pressure should be documented as per standard practice, regardless of age.
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A nurse is using active listening as a form of therapeutic communication when:
- A. She uses humor to put the client at ease in a situation
- B. She restates what the client said in slightly different words
- C. She uses eye contact and maintains an open stance while the client is talking
- D. She provides personal information to show the client she can relate to him
Correct Answer: C
Rationale: The correct answer is C because using eye contact and maintaining an open stance while the client is talking demonstrates active listening. Eye contact shows attentiveness and respect, while an open stance conveys empathy and receptiveness. This non-verbal communication encourages the client to feel heard and understood, fostering a therapeutic relationship.
Choice A is incorrect because using humor may not always align with the client's feelings or be perceived as appropriate. Choice B is incorrect as restating what the client said is a form of paraphrasing, not active listening. Choice D is incorrect because providing personal information can shift the focus away from the client's needs and may breach professional boundaries.
A physician has written an order for '2.0 mg MS q 2-4 hr prn pain.' What is the nurse's appropriate response to this order?
- A. Give 2 mg of morphine sulfate to the client
- B. Give 20 mg of morphine sulfate to the client
- C. Contact the pharmacy to clarify the order
- D. Contact the physician to rewrite the order
Correct Answer: D
Rationale: The correct answer is D: Contact the physician to rewrite the order. The order '2.0 mg MS q 2-4 hr prn pain' is ambiguous as it does not specify the maximum dose within the 2-4 hour range. The nurse should clarify with the physician to ensure patient safety and accuracy in medication administration. Option A is incorrect as it assumes the dose without clarification. Option B is incorrect as it provides an incorrect dose. Option C is not the most appropriate initial action as contacting the physician directly is crucial.
At the beginning of her shift in a long-term care facility, which of the following clients should a nurse check on first?
- A. A 91-year-old man who needs help eating breakfast
- B. An 86-year-old man who has been incontinent in his bed
- C. An 82-year-old woman who needs IV antibiotics
- D. A 75-year-old man who is recovering from an injury and needs an ice pack
Correct Answer: C
Rationale: The correct answer is C: An 82-year-old woman who needs IV antibiotics. Checking on this client first is crucial because IV antibiotics are time-sensitive and require proper administration to ensure the effectiveness of treatment. Delaying or missing a dose can have serious consequences for the client's health. The other choices, while important, can be prioritized after attending to the client needing IV antibiotics. A: The 91-year-old man needing help eating breakfast can wait a bit longer. B: The 86-year-old man who has been incontinent can be addressed after the client needing IV antibiotics. D: The 75-year-old man recovering from an injury and needing an ice pack can also be attended to after the client requiring IV antibiotics.
A client in the emergency room enters the care area to start an IV. He finds a man sitting on the table, hunched over, and attempting to take deep breaths. He states, 'my chest hurts so much!' His wife is sitting on a chair in the corner, crying. Which of the following is the first action of the client?
- A. Bring the IV kit and quickly start an IV
- B. Assess his breathing and provide oxygen, if necessary
- C. Administer medication to control chest pain
- D. Talk with his wife and find out why she is crying
Correct Answer: B
Rationale: The correct answer is B: Assess his breathing and provide oxygen if necessary. This is the first action the client should take because the patient is presenting with chest pain and difficulty breathing, which could indicate a serious medical condition like a heart attack or pulmonary embolism. By assessing the patient's breathing and providing oxygen if needed, the client can help stabilize the patient's condition and ensure proper oxygenation. Starting an IV or administering medication should come after assessing and stabilizing the patient's respiratory status. Talking with the wife, while important for gathering information, is not the priority in this situation.
A nurse is performing an end-of-shift count of narcotics kept in the locked cabinet. The narcotic log states there should be 26 oxycodone pills left, but there are only 24 in the drawer. What is the first action of the nurse?
- A. Perform the count again
- B. Contact the pharmacy to determine if the narcotic log is incorrect
- C. Check with the last nurse to sign out narcotics from the system
- D. Notify the house supervisor that narcotic medications are missing
Correct Answer: A
Rationale: The correct answer is A: Perform the count again. The nurse should double-check the count to ensure accuracy before taking further action. Performing the count again helps to rule out any possible errors in the initial count. This step ensures that the discrepancy is not due to a simple mistake or oversight. Contacting the pharmacy (B), checking with the last nurse who signed out narcotics (C), or notifying the house supervisor (D) should be done after confirming the discrepancy through a recount. The first action should always be to verify the count internally before involving external parties or escalating the issue.