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While obtaining a lie-sit-stand blood pressure reading on a client, what action is most important for the nurse to implement?
- A. Stay with the client while the client is standing.
- B. Record the findings on the graphic sheet in the chart.
- C. Keep the blood pressure cuff on the same arm.
- D. Record changes in the client's pulse rate.
Correct Answer: A
Rationale: The most crucial action for the nurse to implement when obtaining a lie-sit-stand blood pressure reading is to stay with the client while the client is standing. This is essential to monitor the client's immediate response to position changes and ensure their safety. Recording the findings on the graphic sheet is important for documentation but is not as critical as staying with the client. Keeping the blood pressure cuff on the same arm helps maintain consistency in readings but is not as vital as ensuring client safety. Recording changes in the client's pulse rate is important for a comprehensive assessment but does not take precedence over monitoring the client during position changes.
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The nurse-manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to prevent complications of immobility. Which intervention should be included in this instruction?
- A. Perform range-of-motion exercises to prevent contractures.
- B. Decrease the client's fluid intake to prevent diarrhea.
- C. Massage the client's legs to reduce embolism occurrence.
- D. Turn the client from side to back every shift.
Correct Answer: A
Rationale: Performing range-of-motion exercises is beneficial in reducing contractures around joints, maintaining joint mobility, and preventing stiffness in immobile clients. This intervention helps preserve muscle strength and joint function. Options B, C, and D are incorrect because: Option B suggesting decreasing fluid intake to prevent diarrhea is not relevant to preventing complications of immobility and could lead to dehydration; Option C, massaging the client's legs to reduce embolism occurrence, is not a recommended practice as massage can dislodge blood clots and increase the risk of embolism; Option D, turning the client from side to back every shift, is not sufficient as it does not address the need for maintaining joint mobility and preventing contractures in immobile clients.
A male client is laughing at a television program with his wife when the evening nurse enters the room. He says his foot is hurting and he would like a pain pill. How should the nurse respond?
- A. Ask him to rate his pain on a scale of 1 to 10.
- B. Encourage him to wait until bedtime so the pill can help him sleep.
- C. Attend to the acutely ill client's needs first because this client is laughing.
- D. Instruct him in the use of deep breathing exercises for pain control.
Correct Answer: A
Rationale: Obtaining a subjective estimate of the pain experience by asking the client to rate his pain helps the nurse determine which pain medication should be administered and also provides a baseline for evaluating the effectiveness of the medication. Medicating for pain should not be delayed to use it as a sleep medication, so encouraging him to wait until bedtime is incorrect. Option C is judgmental and inappropriate as all clients deserve prompt attention. Option D should be used as an adjunct to pain medication, not instead of medication, so instructing him in deep breathing exercises alone is not the priority in this situation.
The nurse is teaching an obese client, newly diagnosed with arteriosclerosis, about reducing the risk of a heart attack or stroke. Which health promotion brochure is most important for the nurse to provide to this client?
- A. Monitoring Your Blood Pressure at Home
- B. Smoking Cessation as a Lifelong Commitment
- C. Decreasing Cholesterol Levels Through Diet
- D. Stress Management for a Healthier You
Correct Answer: C
Rationale: The most important health promotion brochure to provide to an obese client newly diagnosed with arteriosclerosis is one focused on decreasing cholesterol levels through diet. Arteriosclerosis is significantly influenced by excess dietary fat, especially saturated fat and cholesterol. Monitoring blood pressure at home, while important, does not directly address the underlying cause of arteriosclerosis. Smoking cessation and stress management are crucial for overall cardiovascular health, but lowering cholesterol through diet takes precedence in this scenario.
After a needle stick occurs while removing the cap from a sterile needle, which action should the nurse take?
- A. Complete an incident report.
- B. Select another sterile needle.
- C. Disinfect the needle with an alcohol swab.
- D. Notify the supervisor of the department immediately.
Correct Answer: B
Rationale: After a needle stick, the needle is considered contaminated and should be discarded. The nurse should select another sterile needle to use. Completing an incident report is not necessary in this situation because the needle was sterile when the nurse was stuck and not in contact with any other person's body fluids. Notifying the supervisor immediately is not required as the situation can be managed by selecting a new needle. Disinfecting the needle with an alcohol swab is not recommended as it does not meet the standards of safe practice and infection control.
A client arrives at an occupational health clinic after being struck by lightning while working in a truck bed. The client is alert but reports feeling faint. Which assessment will the nurse perform first?
- A. Pulse characteristics
- B. Open airway
- C. Entrance and exit wounds
- D. Cervical spine injury
Correct Answer: A
Rationale: Assessing pulse characteristics is the priority in this situation due to the potential impact of lightning as a form of electrical current, which can cause irregular heart rhythms. It is crucial to evaluate the pulse rate and regularity to assess for adequate circulation and potential cardiac issues. Since the client is alert and talking, the airway is likely patent, making assessing the airway less urgent. Entrance and exit wounds and cervical spine injury assessments should follow the evaluation of pulse characteristics to ensure proper circulation and prioritize life-threatening issues first. Checking the pulse first will guide further interventions and help in determining the client's hemodynamic status.