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:

Having a cup of hot cocoa immediately before bedtime is not advisable as it contains caffeine, which can interfere with sleep. Herbal teas or warm milk are better alternatives to promote relaxation and sleep.

B reason:

Walking briskly for 30 minutes before bedtime can be stimulating rather than relaxing. While regular exercise is beneficial for sleep, it is best performed earlier in the day. Exercise close to bedtime can increase alertness and make it harder to fall asleep.

C reason:

Doing muscle relaxation techniques each afternoon is beneficial, but the focus should be on practicing these techniques before bedtime to help wind down and prepare for sleep. Afternoon relaxation is good but not directly related to sleep promotion.

D reason:

Avoiding alcohol before bedtime is correct. Although alcohol may initially make one feel drowsy, it can disrupt sleep patterns and reduce sleep quality. Abstaining from alcohol before bed is a positive step toward improving sleep.

A. Withdraw 3 to 5 mL of urine from the port B. Insert the needle into the needleless port at a 60-degree angle C. Wipe the area of the needleless port with sterile water D. Don sterile gloves

Correct Answer is A

Explanation

A reason:

Withdrawing 3 to 5 mL of urine from the port is correct. This amount is typically sufficient for a culture and sensitivity test. It ensures that a fresh sample is obtained for accurate testing.

B reason:

Inserting the needle into the needleless port at a 60-degree angle is incorrect. Most needleless ports are designed to be accessed straight on, not at an angle, to prevent damage to the port.

C reason:

Wiping the area of the needleless port with sterile water is incorrect. The port should be cleaned with an antiseptic solution, such as alcohol, to disinfect the area and prevent contamination of the urine sample.

D reason:

Donning sterile gloves is not typically required for this procedure. Clean gloves are usually sufficient unless the protocol specifies otherwise. The priority is to ensure aseptic technique when handling the catheter and obtaining the sample.

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Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who reports insomnia about promoting rest and sleep. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

Correct Answer is D

Explanation

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?

Correct Answer is A

Explanation

A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take?

A nurse instructs a female client about collecting a midstream urine sample. Which of the following client statements indicates an understanding of the procedure?

A nurse is providing hygiene care for a client who is immobile. Which of the following actions should the nurse take? (Select all that apply.)

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 provider prescribes a sublingual medication for a client who has an NG tube in place. Which of the following actions should the nurse take?

A nurse is assessing a client who has a pressure ulcer. The nurse should recognize which of the following findings is a manifestation of a stage 3 pressure ulcer?

A nurse is preparing a sterile field. Which of the following actions should the nurse identify as contaminating the field?