A nurse is preparing to check a client's blood pressure. Which of the following actions should the nurse take?

Use a cuff with a width that is about 60% of the client's arm circumference.

Release the pressure on the client's arm 5 to 6 mm per second.

Apply the cuff above the client's antecubital fossa

Have the client sit with his arm resting above the level of his heart.

Answer and Explanation

Correct Answer : A,B

A cuff that is too narrow or too wide can result in inaccurate blood pressure readings. The cuff should be snug but not tight and cover about 80% of the arm length. The pressure should be released at a rate of 2 to 3 mm per second to avoid missing auscultatory gaps or causing discomfort to the client.

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Correct Answer is D

Explanation

The nurse should encourage the client to make choices regarding hygiene, as this respects the client's autonomy and dignity. Suctioning the client's airway every hour is incorrect because it may cause discomfort and distress to the dying client. Offering the client sips of a citrus flavored soda is incorrect because it may irritate the client's mouth and throat, which are often dry and sensitive at the end of life. Positioning the client supine in bed is incorrect because it may increase the risk of aspiration and airway obstruction, as well as pressure ulcers.

A. Ensure that the provider signs the prescription. B. Document the prescription as a telephone prescription in the medical record. C. Read back the prescription to the provider D. Write down the complete prescription.

Correct Answer is C

Explanation

The rationale for this answer is that reading back the prescription to the provider is a safety measure that helps prevent medication errors and ensures accuracy and clarity of communication. It also allows for confirmation and verification of any unclear or incomplete information.

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A nurse is preparing to check a client's blood pressure. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing end-of-life care for a client. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse receives a new prescription over the telephone from a client's provider. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse is monitoring a client who is receiving continuous IV fluid therapy via a peripheral vein in the left forearm. Which of the following findings indicates that the client has developed phlebitis at the IV site?

A nurse is teaching a client who requires maximal support about how to use a two-wheeled walker. Which of the following actions by the client indicates an understanding of teaching?

A nurse is caring for a client who is receiving enteral feedings via NG tube. Which of the following actions should the nurse take prior to administering the formula?

A nurse is planning to delegate client care to an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?

A nurse is caring for a client who reports that she has insomnia. Which of the following interventions is appropriate for the nurse to recommend?

A nurse is speaking with the partner of a client who is unconscious and has a do-not resuscitate (DNR) order in place. The partner requests that CPR be performed if necessary. Which of the following responses should the nurse make?

A nurse is assessing the visual acuity of a client who wears glasses using a Snellen chart. Which of the following actions should the nurse take?

A nurse is providing instruction to a client who has diabetes mellitus about foot care. Which of the following statements by the client indicates an understanding of the teaching?