A new patient is visiting a health clinic for the first time for a physical examination. The nurse obtains the patient’s medical history and the patient reports no history of chronic illness or disease and has been very healthy. The patient reports that they have not been seen by a physician for a physical examination in 2 years. The patient states “I am fearful of doctors and I am nervous about being here”. The nurse begins their assessment by collecting vital signs and notes the patient’s blood pressure reading is 130/90 mm Hg in the patient’s right arm while sitting. What would be the priority for the nurse to do next?

Allow the patient to relax and then recheck the patient’s B/P in 5 minutes.

Document the elevated B/P and notify the physician immediately

Begin education related to hypertension (high B/P)

Schedule the patient for follow-up visits for measurement and monitoring of patient’s blood pressure

Answer and Explanation

The Correct Answer is A

A. Allow the patient to relax and then recheck the patient’s B/P in 5 minutes:

The initial elevated blood pressure reading could be influenced by the patient's anxiety about visiting the doctor. Allowing the patient to relax and rechecking the blood pressure after a few minutes may provide a more accurate reading.

B. Document the elevated blood pressure and notify the physician immediately:

It is premature to immediately notify the physician based on a single elevated blood pressure reading. Reassessing after the patient has had time to relax is a reasonable approach before taking further action.

C. Begin education related to hypertension (high blood pressure):

While patient education is important, addressing the patient's anxiety and obtaining accurate blood pressure readings should be the initial focus.

D. Schedule the patient for follow-up visits for measurement and monitoring of the patient’s blood pressure:

Scheduling follow-up visits may be necessary based on subsequent assessments, but the immediate concern is to recheck the blood pressure after allowing the patient to relax.

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Correct Answer is C

Explanation

A. 30 degrees:

This angle does not meet the criteria for a High Fowler's position, which requires a more upright position.

B. 15 to 20 degrees:

This angle is lower than what is generally considered as High Fowler's position. High Fowler's is a more upright position.

C. 90 degrees:

High Fowler's position involves elevating the head of the bed to 90 degrees. This position is often used for better lung expansion and respiratory function.

D. 45-60 degrees:

While this range is higher than a semi-Fowler's position, it is not as upright as the 90-degree elevation in a High Fowler's position.

A. Tie it to the bed frame with a quick release knot B. Strap the restraint with a square knot to the head of the bed C. Use a quick release knot to tie the restraint to the side rail D. Assist with range of motion at least every 3 hours

Correct Answer is A

Explanation

A. Tie it to the bed frame with a quick release knot.This option is correct because securing the restraint to the bed frame ensures that the client cannot easily remove it, while a quick release knot allows for rapid removal in case of an emergency.

B. Strap the restraint with a square knot to the head of the bed.While a square knot may be secure, it is not considered a quick-release method, which is essential for the safety of the client.

C. Use a quick release knot to tie the restraint to the side rail.Tying a restraint to the side rail can pose a risk because if the side rail is lowered, it may create a situation where the restraint is loose or ineffective. It is safer to secure it to the bed frame instead.

D. Assist with range of motion at least every 3 hours.While providing range of motion is important to prevent complications from immobility, it does not address how to secure the restraint itself. Regular assessments and range of motion exercises should be part of the overall care plan but are not directly related to securing the restraint.

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Naxlex Comprehensive Predictor Exams

The physician’s admitting orders indicate that the client is to be placed in a High Fowler’s position. Upon positioning this client, how much will the nurse elevate the head of the bed?

Correct Answer is C

Explanation

The nurse is applying a wrist restraint on a client who has pulled out his IV multiple times. How should the nurse secure this device?

Correct Answer is A

Explanation

A nurse is administering enoxaparin 40mg subcutaneous to a client for prevention of blood clots when the client suddenly moves causing the needle to exit the client’s tissue and stick the nurse’s finger. What is the nurse’s first priority action?

The nurse is providing oral care for a client who is weak, drowsy, and unable to take anything by mouth (NPO). Which of the following would the nurse implement when performing appropriate oral care for this client?

Nursing in the United States is regulated by the state nurse practice act. What is a common element of each state’s nurse practice act?

A nurse is caring for a comatose patient and applies a hand and wrist roll in each hand of the patient to keep the thumb slightly adducted and correct position to the fingers. What is the primary purpose of this action?

The nurse assists the client back to bed from the bedside commode. What is the most important action the nurse can take to assure client safety prior to leaving the room?

The nurse is taking a radial pulse and assessing the pulse amplitude for a patient. Documentation by the nurse states. “Pulses are +3 in the upper extremities.” What amplitude is the nurse assessing?

The nurse understands that sequential compression devices and compression stockings are used for which of the following?

The nursing process guides nurses in delivery of care and includes sequential steps. Which step does the registered nurse (RN) perform within the nursing process that is not part of the standard of practice for the licensed practical nurse (LPN)?