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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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Report the injury to a nurse manager:

While reporting the incident is important, the immediate action to take is cleaning the affected area to minimize the risk of infection.

B. Wash the affected area with soap and water:

This is the immediate priority to reduce the risk of potential infection or transmission of any contaminants from the needlestick injury.

C. Report the needle stick to the infection control department:

Reporting the incident is essential, but it should follow the immediate step of cleaning the affected area to prevent infection.

D. Scrub the area with hand sanitizer for a full 2 minutes:

Hand sanitizer may not be as effective as soap and water in removing contaminants from a needlestick injury site. Washing with soap and water is more appropriate for cleaning the area.

A. Use standard precautions in caring for all clients B. Place all post-surgical clients in contact isolation C. Order IV antibiotics for all clients with sacral pressure wounds D. Limit visitations to 2 people a day for each client

Correct Answer is A

Explanation

A. Use standard precautions in caring for all clients:

Standard precautions involve applying infection prevention practices to all clients, regardless of their known or suspected infectious status. This includes hand hygiene, use of personal protective equipment (PPE), and safe injection practices. Standard precautions are designed to prevent the transmission of microorganisms and break the chain of infection.

B. Place all post-surgical clients in contact isolation:

Contact isolation is typically used for clients with known or suspected infections that can be spread through direct or indirect contact. Placing all post-surgical clients in contact isolation may not be necessary unless there is evidence of a specific infectious condition.

C. Order IV antibiotics for all clients with sacral pressure wounds:

Ordering antibiotics is a specific treatment for bacterial infections but does not address the broader approach of breaking the chain of infection for all clients.

D. Limit visitations to 2 people a day for each client:

While limiting visitations can reduce the risk of introducing infections, it does not address the nurse's direct care practices and adherence to infection prevention measures.

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

Explanation

Which of the following interventions would best assist the nurse in breaking the chain of infection for all clients?

Correct Answer is A

Explanation

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?

A nurse is ambulating a client who catches her foot on the bed frame and begins to fall. Which of the following is an accurate step to prevent or minimize damage from this fall?

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)?

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?

Various sounds are heard when assessing a blood pressure. What does the second sound heard through the stethoscope represent?

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?