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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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

A. Perform oral hygiene at least every 2 hours:

Regular oral care is essential to maintain oral health, prevent infections, and provide comfort. When a client is NPO, and especially if they are weak or drowsy, the nurse should perform oral care at least every 2 hours to keep the oral cavity moist, reduce the risk of infection, and provide comfort.

B. Client must be supine with the head of the bed below 30 degrees:

Keeping the head of the bed elevated to at least 30 degrees is important for preventing aspiration and promoting respiratory function. This position is not specific to oral care but is a general guideline for managing clients at risk for aspiration.

C. Use alcohol-based mouth rinse with oral swab:

Alcohol-based mouth rinses can be drying and may not be suitable for a client who is NPO, as they might contribute to further dryness of the oral mucosa. Non-alcohol-based mouth rinses or moistened oral swabs are often preferred.

D. Assist the client with oral care by brushing their teeth twice daily:

While regular oral care is important, the frequency of twice daily brushing may not be sufficient for a weak, drowsy client, especially if they are NPO. Oral care should be performed more frequently to maintain oral hygiene.

A. To prevent contractions in the hand. B. To prevent skin breakdown. C. To prevent decrease perfusion in the lower extremities. D. To prevent pooling of blood in the hand.

Correct Answer is A

Explanation

A. To prevent contractions in the hand:

The use of hand and wrist rolls helps prevent contractures, which are permanent shortening of muscles or joints. This is particularly important in comatose patients or those with limited mobility to maintain proper hand positioning and prevent deformities.

B. To prevent skin breakdown:

While proper positioning can contribute to preventing skin breakdown, the primary purpose of hand and wrist rolls, in this context, is to address the risk of contractures rather than skin breakdown.

C. To prevent decreased perfusion in the lower extremities:

The action described is specifically related to the hands and wrists, not the lower extremities. It is not designed to prevent decreased perfusion in the lower extremities.

D. To prevent pooling of blood in the hand:

While maintaining proper hand positioning may contribute to optimal circulation, the primary purpose is to prevent contractures rather than addressing blood pooling.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is A

Explanation

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?

Correct Answer is A

Explanation

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

A nurse is caring for a patient who has a low platelet count and is at risk for bleeding. Which of the following is a critical factor or priority that the nurse should apply when considering how to obtain the patient’s vital signs?

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 nurse is caring for a client who has been on bed rest. The primary care provider has just written a new order for the client to sit in the chair three times a day. Which of the following is the best action to transfer the client, for the first time, safely into the chair?

A nurse is providing oral care to a client with dentures. What action would the nurse do first?

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?