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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

A reason:

Identifying delayed gastric emptying is correct. Measuring gastric residual volumes helps to assess whether the stomach is emptying properly. High residual volumes can indicate delayed gastric emptying, which can increase the risk of aspiration and other complications.

B reason:

Removing gastric acid to prevent dyspepsia is not the purpose of measuring gastric residuals. While managing gastric contents is important, the primary reason for checking residuals in this context is to assess gastric emptying.

C reason:

Determining electrolyte balance is not the purpose of measuring gastric residuals. Electrolyte balance is typically assessed through blood tests, not by measuring gastric residuals.

D reason:

Confirming the placement of the NG tube is not the purpose of measuring gastric residuals. Tube placement should be confirmed through initial radiographic verification and regular checks, such as auscultation and pH testing, rather than by measuring residual volumes.

A. Gown B. Face shield C. Mask D. Gloves

Correct Answer is D

Explanation

A reason:

Removing the gown first is not correct. The gown should be removed after the gloves because the gloves are more likely to be contaminated.

B reason:

Removing the face shield first is not correct. The face shield is often removed after the gloves and gown to prevent contamination of the face and eyes.

C reason:

Removing the mask first is not correct. The mask should be removed last to ensure that no contaminants are inhaled during the removal process.

D reason:

Removing the gloves first is correct. The gloves are typically the most contaminated PPE item. Removing them first reduces the risk of transferring contaminants to other parts of the body or other PPE.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?

Correct Answer is A

Explanation

A nurse is removing personal protective equipment (PPE) after giving direct care to a client who requires isolation. Which of the following PPE items should the nurse remove first?

Correct Answer is D

Explanation

A nurse is teaching a client who has a history of falls about home safety. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

A nurse is caring for a client who has active pulmonary tuberculosis (TB). The client requires airborne precautions and is receiving multidrug therapy. Which of the following precautions should the nurse take to transport the client safely to the radiology department for a chest x-ray?

A nurse is teaching an older adult client who has left-sided weakness about cane use. Which of the following instructions should the nurse include?

Before administering a medication to a client, the nurse must identify the client. Which of the following methods of identification should the nurse use?

An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1°C (98.8°F), pulse 92/min, respiratory rate 18/min, and BP 98/58 mm Hg. Which of the following vital signs should the nurse re-measure?

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 caring for a client who has an indwelling urinary catheter and a prescription for a urine specimen for culture and sensitivity. Which of the following actions should the nurse take?

A nurse is preparing to assist a client who can partially bear weight and is cooperative with transfer from the bed to a chair. Which of the following actions should the nurse take to maintain safety during the transfer?