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 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?

The unlicensed assistive personnel reports vital signs for a patient to the nurse: Oral Temperature of 99.2 degrees Fahrenheit. Radial pulse of 88 bpm and regular, Respirations of 18 bpm and regular, blood pressure supine in left arm of 178/112 mm Hg. and oxygen saturation of 95% on room air. Which vital sign should the nurse be most concerned about?

The nurse on the progressive care unit is preparing to perform a sterile wet to dry dressing change on a client with a sacral pressure ulcer. The nurse notes that the sterile saline at the bedside is marked as opened 48 hours ago. What is the nurse’s priority action?

The nurse would recognize which of the following patients would be at highest risk for developing an infection?

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 is performing a respiration assessment on her client. The nurse begins counting the respirations when the second hand on the clock is at 12. When the nurse looks at the chest of the client he is exhaling. The client then continues to inhale and exhale 9 times. When the second hand on the clock is just past 5 the patient begins to inhale. When the second hand reaches the 6 the client has not exhaled. What would the nurse record in the chart as this client’s respiratory rate?

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

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?

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?

A nurse is assessing the level of consciousness of a patient who has sustained a head injury in a motor vehicle accident. The nurse notes that the patient appears drowsy but the nurse is able to wake the patient by gently shaking and calling the patient by name. What level of consciousness would the nurse document?