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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Listening as the patient inhales and then going to the next site during exhalation. This method does not allow for a complete assessment of breath sounds, as abnormalities may be present during either phase of respiration.
B. If the patient is modest, listening to sounds over his or her clothing or hospital gown. Clothing can muffle or distort breath sounds, leading to inaccurate assessments. The stethoscope should be placed directly on the skin.
C. Instructing the patient to breathe in and out rapidly while listening to the breath sounds. Rapid breathing may lead to hyperventilation and dizziness, and it can make it difficult to detect subtle abnormalities such as crackles or wheezes.
D. Listening to at least one full respiration in each location. This is the correct technique because it allows the nurse to fully assess breath sounds during both inhalation and exhalation, ensuring accurate identification of any abnormal sounds.
Correct Answer is ["2"]
Explanation
Calculation:
To determine the number of tablets per dose, use the formula:
Tablets per dose = Dose ordered/ Dose available
Given:
- Ordered dose = 10 mg
- Available dose = 5 mg per tablet
Tablets per dose = 10mg/ (5mg/tablet)
= 2 tablets
Thus, the nurse will administer 2 tablets per dose.
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