Choice A rationale:

Encouraging range-of-motion exercises of the foot is not advisable because it can cause further injury to the ankle.

Choice B rationale:

Providing the client with a light snack is not directly related to the care of an ankle injury.

Choice C rationale:

Applying ice to the ankle can help reduce swelling and pain.

Choice D rationale:

Applying a compression bandage can help reduce swelling.

Choice E rationale:

Elevating the foot can help reduce swelling by promoting venous return.

Choice A rationale:

Asking the client’s full name and date of birth is the most reliable method of identification.

Choice B rationale:

Verifying the client’s room number is not reliable because room assignments can change.

Choice C rationale:

Asking a family member to verify the client’s identity is not always possible or reliable.

Choice D rationale:

Checking the client’s name on the medication administration record (MAR) is important but should be done in conjunction with direct client identification.

Choice A rationale:

Requesting a prescription for an analgesic for the client is a part of conventional medical treatment.

Choice B rationale:

Checking the client’s oxygen saturation level is a part of conventional medical treatment.

Choice C rationale:

Encouraging the client to take slow, deep breaths can help manage pain and is a holistic nursing approach.

Choice D rationale:

Obtaining blood work from the client is a part of conventional medical treatment.

Choice A rationale:

Decreased deep-tendon reflexes are not a common symptom of hypocalcemia. Normal calcium levels in the blood range from 8.5 to 10.2 mg/dL1.

Choice B rationale:

Skeletal muscle weakness is a symptom of hypercalcemia, not hypocalcemia.

Choice C rationale:

Hypoactive bowel sounds are associated with hypercalcemia, not hypocalcemia.

Choice D rationale:

Tingling of the lips is a common symptom of hypocalcemia. This occurs due to increased excitability of the nerves.

The correct answer is choice B.

Choice A rationale:

A blood pressure of 108/60 mm Hg is considered normal, as it is less than 120/80 mm Hg.

Choice B rationale:

A blood pressure of 154/96 mm Hg falls into the category of stage 1 hypertension. Stage 1 hypertension is classified as a systolic blood pressure reading that falls between 130 and 139 mm Hg or a diastolic reading that is between 80 and 89 mm Hg.

Choice C rationale:

A blood pressure of 164/104 mm Hg is considered stage 2 hypertension, as the systolic blood pressure is 140 mm Hg or higher, or the diastolic pressure is 90 mm Hg or higher.

Choice D rationale:

A blood pressure of 128/88 mm Hg is considered elevated, as the systolic blood pressure ranges from 120 to 129 mm Hg and the diastolic blood pressure is below 80 mm Hg.

Choice A rationale:

Respiratory acidosis is characterized by a high PaCO2 and a low pH. The client’s ABG results do not match this pattern.

Choice B rationale:

Metabolic acidosis is characterized by a low HCO3 and a low pH. The client’s ABG results do not match this pattern.

Choice C rationale:

Respiratory alkalosis is characterized by a low PaCO2 and a high pH. The client’s ABG results do not match this pattern.

Choice D rationale:

Metabolic alkalosis is characterized by a high HCO3 and a high pH. The client’s ABG results match this pattern. Normal values for pH, PaCO2, and HCO3 are 7.35-7.45, 35-45 mm Hg, and 22-26 mEq/L respectively.

Choice A rationale:

This statement is incorrect. Veins do not carry oxygenated blood away from the heart, and arteries do not carry deoxygenated blood toward the heart.

Choice B rationale:

This statement is incorrect. While it is true that veins carry deoxygenated blood, they carry it toward the heart, not away from it. Similarly, arteries carry oxygenated blood, but they carry it away from the heart, not toward it.

Choice C rationale:

This statement is correct. In the circulatory system, veins carry deoxygenated blood toward the heart, while arteries carry oxygenated blood away from the heart.

Choice D rationale:

This statement is incorrect. Veins do not carry oxygenated blood toward the heart, and arteries do not carry deoxygenated blood away from the heart.

Choice A rationale:

Increased deep tendon reflexes are not typically associated with anaphylaxis. This is more commonly seen in conditions affecting the nervous system.

Choice B rationale:

While erythema of the skin can occur in anaphylaxis, it is not the most indicative symptom of this condition.

Choice C rationale:

Bradycardia is not typically associated with anaphylaxis. Anaphylaxis is more likely to cause tachycardia, or a rapid heart rate.

Choice D rationale:

Hypotension, or low blood pressure, is a common symptom of anaphylaxis. This occurs due to widespread vasodilation in response to the allergen.

Choice A rationale:

The thickest part of the heart is not the upper chambers but the lower chambers, specifically the left ventricle. This is because it needs to pump blood to the entire body.

Choice B rationale:

Blood leaves the heart through the lower chambers, or ventricles, not the upper chambers.

Choice C rationale:

Blood enters the heart through the upper chambers, or atria. This is where deoxygenated blood from the body and oxygenated blood from the lungs first enter the heart.

Choice D rationale:

The term “ventricles” refers to the lower chambers of the heart, not the upper chambers.

Choice A rationale:

Tilt the head and lift the chin is a technique used to open the airway in an unconscious client, not a conscious one with an airway obstruction.

Choice B rationale:

Turning the client to the side is not the first action to take when a client is conscious and has an airway obstruction.

Choice C rationale:

The Heimlich maneuver is the appropriate action to take for a conscious client who has an airway obstruction. It works by creating an artificial cough, intended to force the obstruction out.

Choice D rationale:

A blind finger sweep should never be performed because it can push the obstruction further into the airway.