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 D

Explanation

Choice A reason: Meningococcal vaccine starts at 11-12 years, not infancy; three doses by kindergarten is incorrect. Scientifically, this misaligns with CDC schedules, as 2-month-olds get other vaccines (e.g., DTaP), showing misunderstanding of immunization timing.

Choice B reason: No feeding restriction exists for immunizations; fasting isn’t required. Scientifically, nutrition supports immune response, and this contradicts standard practice, as feeding doesn’t affect vaccine efficacy or safety, indicating a preparation misconception.

Choice C reason: High fever for 24 hours isn’t typical; mild fever may occur but not guaranteed. Scientifically, this exaggerates normal vaccine reactions (e.g., low-grade fever), misrepresenting expected immune responses, suggesting inaccurate outcome expectations.

Choice D reason: Rotavirus vaccine is oral at 2 months, per CDC schedule, aligning with its live attenuated form. Scientifically, this reflects correct administration knowledge, as it targets gut immunity, showing the guardian understands this immunization’s delivery accurately.

A. Puffed rice cereal B. Tomato juice C. Bran muffin D. Cottage cheese E. None F. None

Correct Answer is C

Explanation

Choice A reason: Puffed rice cereal lacks significant fiber, offering minimal bulk to stimulate peristalsis. It’s a poor choice for constipation relief, as it doesn’t soften stool or aid movement.

Choice B reason: Tomato juice provides hydration and some nutrients, but its low fiber content doesn’t effectively combat constipation. High-fiber foods are needed to increase stool bulk instead.

Choice C reason: Bran muffins are high in insoluble fiber, adding bulk and water to stool, promoting bowel movements. This choice reflects understanding of constipation management through diet.

Choice D reason: Cottage cheese is low in fiber, offering protein but no relief for constipation. It doesn’t enhance intestinal motility or stool consistency, making it an ineffective option.

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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

Naxlex Comprehensive Predictor Exams

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