You are assessing a client who has the following vital signs: blood pressure 120/68, pulse 84, respirations 18. You should:

have another nurse recheck your findings for accuracy.

record the vital signs and compare them with previously charted vital signs.

report them to the charge nurse and call the doctor for orders.

instruct the client on diet and exercise for high blood pressure.

Answer and Explanation

The Correct Answer is B

A. Have another nurse recheck your findings for accuracy. The vital signs are within normal limits, so there is no immediate need for validation by another nurse.
B. Record the vital signs and compare them with previously charted vital signs. The patient's blood pressure (120/68 mmHg), pulse (84 bpm), and respirations (18 breaths/min) are within normal ranges. The best action is to document the findings and compare them to previous values to identify any trends or changes.
C. Report them to the charge nurse and call the doctor for orders. Since the vital signs are normal, there is no need for immediate reporting or new medical orders.
D. Instruct the client on diet and exercise for high blood pressure. The blood pressure 120/68 mmHg is not high, so there is no need for immediate education on hypertension management.

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Correct Answer is A

Explanation

A. Carotid. The carotid arteries supply blood to the brain, and compressing both simultaneously can reduce cerebral blood flow, potentially causing dizziness, syncope, or loss of consciousness. Therefore, carotid pulses should be assessed one at a time.
B. Radial. The radial pulse can be safely assessed bilaterally at the same time since it does not affect central circulation or brain perfusion.
C. Brachial. The brachial pulse can also be assessed bilaterally without risk, as it does not impact blood flow to critical organs like the brain.
D. Femoral. The femoral pulse can be checked simultaneously on both sides to assess circulation and perfusion, especially in cases of suspected arterial insufficiency.

A. Distractions such as music B. Massage C. Cold or heat applications D. Vigorous rubbing of the joints E. Relaxation techniques

Correct Answer is ["A","B","C","E"]

Explanation

A. Distractions such as music. Music and other distractions, such as guided imagery or television, can help shift the patient's focus away from pain, reducing discomfort and anxiety.
B. Massage. Gentle massage can help promote relaxation, improve circulation, and reduce muscle tension, which may enhance pain relief when used alongside medication.
C. Cold or heat applications. Cold therapy can help reduce inflammation and swelling, while heat therapy can improve blood flow and relax muscles, making them effective in managing arthritis pain and post-surgical discomfort.
D. Vigorous rubbing of the joints. Vigorous rubbing could worsen pain and cause irritation, particularly in a patient with arthritis and post-surgical pain. Gentle approaches are more appropriate.
E. Relaxation techniques. Deep breathing, guided imagery, and progressive muscle relaxation can help lower stress and enhance the body's ability to manage pain.

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You are assessing a client who has the following vital signs: blood pressure 120/68, pulse 84, respirations 18. You should:

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Explanation

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