The nurse has collected the vital signs on a client who has been on bedrest for a week and just returned from physical therapy. See chart:

- Blood Pressure: 122/84 mmHg

- Heart Rate: 108

- Respiratory Rate: 22

- Oxygen Saturation: 96% on room air

- Temperature: 98.0°F

What action should the nurse take?

Document the client's bradycardia.

Apply oxygen via nasal cannula at 2 liters per minute.

Reassess the vital signs in five minutes.

Notify the provider of the findings.

Answer and Explanation

The Correct Answer is C

A. Documenting bradycardia is incorrect because the client is experiencing tachycardia (HR 108), not bradycardia.
B. Applying oxygen at 2L/min is incorrect because the oxygen saturation is normal (96% on room air). Oxygen therapy is not indicated at this time.
C. Reassess the vital signs in five minutes is correct because the slightly elevated heart rate and respiratory rate may be due to recent physical activity after prolonged bedrest. It is important to allow the client time to recover and reassess before taking further action.
D. Notifying the provider is incorrect because there is no immediate concern; the elevated HR and RR are expected post-activity.

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Correct Answer is A

Explanation

A. Inflating the blood pressure cuff 30 mmHg above the point where the radial pulse disappears is correct. This method, known as the palpatory method, prevents auscultatory gap errors and ensures an accurate blood pressure reading.
B. Assisting the patient to a standing position for five to ten minutes is incorrect unless assessing for orthostatic hypotension. For routine blood pressure measurements, the client should be seated and at rest for at least five minutes.
C. Palpating the radial artery and placing the stethoscope lightly over this area is incorrect because blood pressure is auscultated over the brachial artery, not the radial artery.
D. Measuring the blood pressure cuff to encircle 60% of the client’s arm is incorrect. The correct guideline is that the cuff bladder should encircle at least 80% of the arm circumference, not 60%.

A. "The documentation satisfies legal standards established by health care organizations and institutions." B. "Documentation of the initial assessment becomes the foundation for the entire nursing process." C. "Incorrect conclusions may be made without the documentation of the nurse's opinions." D. "Health care institutions have established policies regarding documentation of initial assessments."

Correct Answer is B

Explanation

A. While documentation does satisfy legal standards, the primary reason for documenting the initial assessment is to guide the entire nursing process.
B. "Documentation of the initial assessment becomes the foundation for the entire nursing process" is correct because all subsequent care planning, interventions, and evaluations depend on accurate initial assessment data.
C. Documentation should be objective, not based on the nurse’s opinions.
D. Institutional policies are important, but the significance of initial assessment documentation lies in its role in guiding patient care.

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Naxlex Comprehensive Predictor Exams

The nurse is assessing vital signs and is preparing to measure the client's blood pressure. Prior to obtaining the blood pressure, what action would be most appropriate?

Correct Answer is A

Explanation

Which of the following statements indicate that the student nurse understands the importance of documenting the initial assessment data?

Correct Answer is B

Explanation

The nurse is inspecting a new client's abdomen and notes the presence of a tight, distended abdomen and visible arterioles on the abdominal skin surface. What would the nurse do next?

A nurse is preparing to examine the chest, extremities, and peripheral pulses of a client who has low back pain. What is the best position to place this client in to assure they are comfortable for the exam?

A nurse is admitting a new client to the subacute medical unit and is completing a comprehensive assessment. The nurse is appropriately applying standard precautions by performing which action below?

The nurse identifies that the patient care tech recorded the client's blood pressure as 78/52. The nurse recognizes this blood pressure is abnormally low for this client. What is the best response by the nurse?

A client has sought care because they are concerned that a mole on the scalp may be skin cancer. Which finding would the nurse identify as being most suggestive of melanoma?

The nurse's auscultation of a client's lung fields reveals the presence of a wheeze. The nurse should recognize that this adventitious sound results from what pathophysiologic process?

A client complains of shortness of breath and having to sleep on three pillows to breathe comfortably at night. During the nurse's examination, what findings will suggest that the cause of this client's dyspnea is due to a heart condition rather than respiratory disease?