A nurse just received a client from the emergency department, who presents to the floor with a history of stroke. He is admitted with left-sided weakness. His vital signs are to be monitored every 4 hours. On initial assessment at 0800 the client's blood pressure was noted to be 150/100. What priority action should the nurse do next?

Check the patient's pulse and temperature.

Have the UAP repeat the blood pressure.

Repeat the blood pressure.

Administer the patient’s morning medications.

Answer and Explanation

The Correct Answer is C

A reason:

Checking the patient's pulse and temperature is important but not the priority. The elevated blood pressure needs to be reassessed first to confirm accuracy before taking further actions.

B reason:

Having the UAP repeat the blood pressure is not appropriate. The nurse should personally repeat the measurement to ensure accuracy and assess for any potential issues immediately.

C reason:

Repeating the blood pressure is the priority. An initial high reading needs to be confirmed to rule out any measurement error and to determine if immediate intervention is needed.

D reason:

Administering the patient's morning medications may be necessary, but confirming the blood pressure reading is more urgent to ensure that any medications given are appropriate for the current condition.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

A reason:

Maintaining the head of the bed in a flat position is incorrect. The head of the bed should be elevated to reduce the risk of aspiration.

B reason:

Mixing the three medications together is incorrect. Medications should be administered separately to avoid potential interactions and ensure the correct dosage of each medication.

C reason:

Diluting each medication with tap water is not recommended. Sterile water or the water specified in the medication guidelines should be used for dilution to maintain safety and prevent contamination.

D reason:

Flushing the NG feeding tube with 30 ml of water immediately following medication administration is correct. This ensures that the medications are cleared from the tube and helps prevent tube blockage.

A. Ignoring the urge to defecate B. Inadequate fluid intake C. Decreased fiber in the diet D. Increased activity E. Excessive laxative use

Correct Answer is ["A","B","C","E"]

Explanation

A reason:

Ignoring the urge to defecate is a common cause of constipation. Suppressing the natural urge can lead to harder stools and decreased bowel movement regularity.

B reason:

Inadequate fluid intake contributes to constipation by leading to harder stools that are more difficult to pass. Sufficient hydration is essential for maintaining regular bowel movements.

C reason:

Decreased fiber in the diet is a significant cause of constipation. Fiber helps to bulk up the stool and promote regular bowel movements. A diet low in fiber can result in harder and less frequent stools.

D reason:

Increased activity typically promotes regular bowel movements and is not a cause of constipation. Physical activity stimulates intestinal motility, helping to prevent constipation.

E reason:

Excessive laxative use can lead to dependence and decreased bowel motility over time, causing constipation. Overuse of laxatives can disrupt the natural bowel rhythm and lead to chronic constipation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous enteral feedings. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is teaching a client who has constipation. Which of the following should the nurse discuss as causes of constipation? (Select all that apply.)

Correct Answer is ["A","B","C","E"]

Explanation

A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

A nurse is caring for a client who requires droplet precautions. Which of the following personal protective equipment should the nurse wear when setting up the client's meal tray?

A nurse is caring for a 65-year-old client admitted to the hospital with symptoms of productive cough, malaise, fever, joint pain, and dehydration. What type of isolation should the patient be placed on and what type of PPE should be used?

A nurse is calculating the total fluid intake for a client during a 4-hr period. The client consumes 1 cup of coffee, 4 oz of orange juice, 3 oz of water, 1 cup of flavored gelatin, 1 cup of tea, 5 oz of broth, and 3 oz of water. The nurse should record how many mL of intake on the client's record?

A nurse is caring for a client who is prescribed bedrest. The plan of care indicates that the client should perform isometric exercises every 2 hours. Which of the following actions should the nurse take as directed by the plan of care?

A nurse is measuring a client's oral temperature. The client informs the nurse that he has just eaten some ice chips. Which of the following actions should the nurse take?

A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?

A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about a client's potential allergies during which phase of the nursing process?