The nurse is assessing the blood pressure of a client diagnosed with hypertension. How should the nurse assess this client's blood pressure?

Take the blood pressure in the same arm at the beginning and end of the check-up.

Compare the blood pressure readings from the upper extremities and lower extremities.

Take a blood pressure with the client sitting down and standing up.

Obtain blood pressure readings from both the client's arms.

Answer and Explanation

The Correct Answer is D

A. Taking blood pressure in the same arm at different times during a check-up is standard for consistency but does not detect inter-arm differences, which can be clinically significant. This approach alone is insufficient for a comprehensive hypertension assessment.

B. Comparing blood pressure between upper and lower extremities is typically done only when coarctation of the aorta or peripheral vascular disease is suspected, not routinely for all clients with hypertension. While informative in specific cases, this is not the standard assessment method.

C. Measuring blood pressure in both sitting and standing positions (orthostatic BP) is important if there is concern for orthostatic hypotension, especially in older adults or those on antihypertensives. While relevant in some cases, this is not the primary approach for general hypertension assessment.

D. Obtaining blood pressure readings from both arms is recommended by current guidelines for clients with hypertension. Inter-arm differences of more than 10–15 mmHg may indicate vascular disease or increased cardiovascular risk, which can influence management decisions. The higher reading is typically used for ongoing monitoring.

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Correct Answer is C

Explanation

A. Monitoring for activity intolerance is important in clients with anemia, which is common in leukemia and chemotherapy due to decreased red blood cells. However, a platelet count of 25,000/mm³ indicates severe thrombocytopenia, placing the client at high risk for bleeding rather than fatigue-related complications. Therefore, while this assessment may be relevant, it is not the priority intervention for this platelet level.

B. Requiring visitors to wear respiratory masks is an infection control measure appropriate for clients with neutropenia (low white blood cell count). Although myelosuppressive chemotherapy can also reduce white blood cells, the question specifically highlights a critically low platelet count. Thus, bleeding—not infection—is the immediate concern, making this option less relevant to the current priority.

C. This is the most important intervention. A platelet count of 25,000/mm³ significantly increases the risk of spontaneous bleeding, including internal bleeding that may not be immediately visible. Assessing urine and stool for occult blood allows for early detection of hidden (internal) bleeding in the gastrointestinal or urinary tract. Early identification enables prompt intervention, such as platelet transfusions or activity restrictions, to prevent life-threatening hemorrhage. Monitoring for bleeding is a priority in severe thrombocytopenia.

D. Monitoring temperature every 4 hours is appropriate for detecting infection, especially in immunocompromised clients. However, this intervention is more directly related to neutropenia rather than thrombocytopenia. While still important in the overall care of a client receiving chemotherapy, it is not the priority given the immediate risk of bleeding associated with the critically low platelet count.

A. Feed the infant on demand. B. Make sure the infant is well rested before feeds. C. Wake the infant up to eat. D. Feed for one-hour duration. E. Initiate a three-hour feeding schedule. F. Slowly increase caloric content using enteral nutritional formula powder. G. Stroke the cheek to encourage sucking. H. Give gavage feedings via percutaneous endoscopic gastrostomy (PEG) tube.

Correct Answer is ["B","C","E","F","G"]

Explanation

A. Infants with heart failure and failure to thrive require structured, energy-efficient feeding schedules rather than feeding on demand. Feeding on demand may lead to missed caloric goals and increased fatigue, as these infants often lack the energy reserves to signal hunger consistently.

B. Infants with heart failure tire easily due to increased metabolic demands and decreased cardiac efficiency. Ensuring the infant is rested before feeding helps conserve energy, allowing for more effective feeding and improved caloric intake.

C. Because of fatigue and poor endurance, these infants may sleep through feeding times and fail to meet nutritional needs. Waking the infant ensures adequate caloric intake and supports weight gain, which is critical in failure to thrive.

D. Prolonged feeding times increase energy expenditure, leading to more calorie loss than gain. Feeds should generally be limited to about 20–30 minutes to prevent fatigue and optimize energy conservation.

E. A structured feeding schedule (e.g., every 3 hours) ensures consistent caloric intake while allowing for rest periods. This approach helps balance nutritional needs with the infant’s limited energy reserves.

F. Increasing caloric density (e.g., from standard to 24–28 cal/oz) allows the infant to receive more calories in smaller volumes, which is essential for infants with fluid restrictions and fatigue. Gradual increases help prevent gastrointestinal intolerance.

G. Stimulating the rooting reflex by stroking the cheek promotes effective sucking and feeding, especially in infants who are fatigued or have weak feeding efforts. This helps maximize intake during limited feeding time.

H. A PEG tube is not a first-line intervention for this infant. Enteral tube feeding may be considered if oral intake is inadequate, but typically nasogastric (NG) feeding is used initially. PEG placement is invasive and reserved for long-term feeding issues.

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The nurse is assessing the blood pressure of a client diagnosed with hypertension. How should the nurse assess this client's blood pressure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with leukemia who is receiving a myelosuppressive chemotherapy has a platelet count of 25,000/mm3 (25 x 109/L). Which intervention is most important for the nurse to include in this client's plan of care? Reference Range: Platelet count [150,000 to 400,000/mm3 (150 to 400 x 109/L)]

Correct Answer is C

Explanation

The nurse has mixed the formula with enteral nutritional formula powder to increase the caloric content to 24 calories per ounce (24 cal/30 mL). Which nursing intervention(s) should the nurse include from the plan of care (POC) to help meet the client's nutritional needs? Select all that apply.

Correct Answer is ["B","C","E","F","G"]

Explanation

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