An adult with a history of cardiovascular disease comes to the clinic complaining of indigestion. Vital signs are heart rate 130 beats/minute, respirations 24 breaths/minute, and blood pressure 180/90 mm/Hg. Which finding should the practical nurse (PN) report immediately to the healthcare provider?

severe headache.

Left jaw discomfort.

Nausea with emesis.

Warm, flushed skin.

Answer and Explanation

The Correct Answer is B

A. Severe headache: While concerning, a headache alone in this context may indicate hypertension or stress, but it is not as immediately life-threatening as potential cardiac ischemia. It should be assessed, but reporting is not the most urgent action.

B. Left jaw discomfort: Discomfort in the left jaw is a classic sign of myocardial ischemia or acute coronary syndrome, particularly in a client with a history of cardiovascular disease. Immediate reporting is essential to initiate prompt evaluation and treatment to prevent complications such as myocardial infarction.

C. Nausea with emesis: Nausea can accompany cardiac events, but by itself it is a nonspecific symptom. It requires monitoring but is not as urgent as signs of potential cardiac ischemia.

D. Warm, flushed skin: This finding may indicate fever or vasodilation, but it is not immediately life-threatening in the context of cardiovascular risk. It should be noted, but it does not necessitate immediate intervention compared with left jaw discomfort.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Call bell, side rails, bed in low position, and ambulation aids: These are safety measures important to prevent falls, but they do not reflect the client’s immediate postoperative neurovascular status or potential complications.

B. Clear lung sounds, CPM (continuous passive motion) on: Monitoring lung sounds and CPM use is part of routine postoperative care. While important, these findings are not as urgent as neurovascular assessments in detecting limb compromise.

C. Paresthesia, paralysis, pedal pulses, pallor, and pain: Documenting changes in sensation, motor function, circulation, or severe pain helps detect complications such as compartment syndrome, vascular compromise, or nerve injury, which require immediate intervention.

D. Blood pressure 138/88, pain scale 7, and respirations 22: Vital signs and pain rating provide useful information on overall status, but they do not specifically address the neurovascular integrity of the operative limb, which is the highest-priority assessment after knee replacement.

A. Release air from the cuff slowly. B. Position the blood pressure cuff. C. Pump the cuff while palpating the pulse. D. Listen for the systolic pressure reading. E. Listen for the diastolic pressure reading.

Correct Answer is B,C,A,D,E

Explanation

A. Release air from the cuff slowly: Air is released gradually (2–3 mmHg per second) to allow accurate identification of Korotkoff sounds while preventing false readings.

B. Position the blood pressure cuff: The PN first places the cuff snugly around the upper arm, ensuring it is at heart level and the artery marker aligns with the brachial artery for accurate measurement.

C. Pump the cuff while palpating the pulse: The PN inflates the cuff until the radial pulse disappears to estimate systolic pressure, helping determine how high to inflate when taking the actual reading.

D. Listen for the systolic pressure reading: The first clear tapping sound heard through the stethoscope indicates the systolic blood pressure — the pressure during ventricular contraction.

E. Listen for the diastolic pressure reading: The disappearance of the sounds marks the diastolic pressure, representing the pressure during ventricular relaxation, which is recorded as the lower number in the BP reading.

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Naxlex Comprehensive Predictor Exams

An older male client is returning to the surgical unit after a total right knee replacement. Which assessment findings are most important for the practical nurse (PN) to document in this client's electronic medical record (EMR)?

Correct Answer is C

Explanation

The practical nurse (PN) is assessing a client's blood pressure using a manual sphygmomanometer on the left arm. In which sequence should the PN implement these actions? (Arrange from first action on top to last on the bottom.)

Correct Answer is B,C,A,D,E

Explanation

The practical nurse (PN) observes an unlicensed assistive personnel (UAP) obtain a client's vital signs. The PN should intervene when observing the UAP performing which technique?

The practical nurse (PN) plans to reinforce the proper use of a cane to an older client who is recovering from a stroke. When providing information to the client how to correctly use this assistive device, where should the PN reinforce with the client to place the cane?

The nurse is very busy and running late with administering medications and asks the practical nurse (PN) to administer a medication already drawn up in an unlabeled syringe. How should the PN respond?

he practical nurse (PN) administers an injection using a syringe with a retractable needle. After the needle is removed from the client's skin, the needle does not retract, and the PN gets stuck in the finger with the used needle. What action should the PN take first?

The practical nurse (PN) is assisting the recreational director of a long-term care facility plan outdoor activities for the wheelchair-bound older residents who are mentally alert. Which activity meets the physical and social needs of these residents?

A practical nurse (PN) is at the nurses' station describing her social life, sexual activities, and alcohol drinking in a boisterous that might be heard by clients and visitors. Which is the best action that a peer PN should do?

A client with paranoia is admitted to the mental health unit and immediately goes to the corner of the room and sits quietly without communicating. In approaching the client, what intervention should the practical nurse (PN) implement first?