A nurse is collecting data from a client who has chronic kidney failure. An assistive personnel reports that the client has a blood pressure of 190/110 mm Hg. Which of the following actions should the nurse take first?

Remeasure the client's blood pressure.

Administer an antihypertensive medication.

Report the blood pressure reading to the charge nurse.

Instruct the client to remain in bed.

Answer and Explanation

The Correct Answer is A

Choice A reason: Remeasuring confirms the 190/110 mm Hg reading, ensuring accuracy in kidney failure, where hypertension is common. It’s the first step before acting.

Choice B reason: Administering medication without verification risks error; BP may be inaccurate. In kidney failure, precise BP guides therapy, so this waits.

Choice C reason: Reporting to the charge nurse follows confirmation; unverified readings waste time. Accuracy in chronic kidney failure is critical before escalating.

Choice D reason: Bed rest may help, but confirming BP first prioritizes data. Kidney failure needs validated hypertension readings to direct immediate care safely.

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Correct Answer is B

Explanation

Choice A reason: Pointing toes eases stocking application, reducing drag on skin. Scientifically, this aligns with proper technique, enhancing venous return without resistance, so no intervention is needed, as it supports effective antiembolic function per guidelines.

Choice B reason: Creases on the front risk pressure sores or impaired circulation, countering antiembolic goals. Scientifically, smooth application prevents venous stasis, requiring intervention, as this error compromises blood flow and skin integrity in at-risk clients.

Choice C reason: Turning stockings inside out aids application, a standard technique for even fit. Scientifically, this ensures proper compression gradient, supporting venous return, so no intervention is warranted, as it’s correct per procedural evidence.

Choice D reason: Applying before getting out of bed maximizes compression benefits, reducing clot risk. Scientifically, this aligns with prophylaxis timing, as gravity aids swelling post-ambulation, making it appropriate and not requiring nurse intervention.

A. Don gloves prior to assisting the client with brushing their teeth. B. Have the client wear a mask when they are out of their room. C. Ensure that the negative air pressure is active for the client's room. D. Place the client in a room with a high-efficiency particulate air (HEPA) filter.

Correct Answer is A

Explanation

Choice A reason: Gloves prevent MRSA spread via contact during oral care, a high-risk task. This adheres to contact precautions for infection control.

Choice B reason: Masks aren’t needed for MRSA patients; it’s not airborne. Contact precautions suffice, so this is unnecessary outside specific contexts.

Choice C reason: Negative pressure suits airborne pathogens, not MRSA, which spreads by contact. This overcomplicates room requirements for this infection.

Choice D reason: HEPA filters address air quality, irrelevant to MRSA’s contact transmission. Standard isolation, not filtration, controls this bacterial spread.

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A nurse is collecting data from a client who has chronic kidney failure. An assistive personnel reports that the client has a blood pressure of 190/110 mm Hg. Which of the following actions should the nurse take first?

Nursing Test Bank

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