a clients blood pressure reading is 15694 mm hg which action should the nurse take first
Logo

Nursing Elites

HESI RN

HESI Fundamentals Quizlet

1. A client's blood pressure reading is 156/94 mm Hg. Which action should the nurse take first?

Correct answer: D

Rationale: The correct action for the nurse to take first in this situation is to compare the current blood pressure reading with the client's previously documented readings. This comparison will provide valuable information about what is normal for this specific client, helping to determine if the current reading represents a significant change or if it falls within the client's usual range. By reviewing the client's past readings, the nurse can assess trends, variations, and if the current reading is an isolated high value or part of a pattern, guiding appropriate decision-making. Informing the client about the high reading (Choice A) or contacting the healthcare provider for medication (Choice B) should come after assessing the client's history. Replacing the cuff (Choice C) is not necessary at this point and does not address the immediate need to compare the readings for appropriate intervention.

2. A client who is in hospice care complains of increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the nurse implement?

Correct answer: A

Rationale: The most effective pain management strategy in hospice care involves administering analgesics on an around-the-clock schedule (A) to maintain pain control. Waiting until pain is severe before administering medication (B) is not ideal as it may lead to inadequate pain relief. While providing comfort is crucial in hospice care, sedation that prevents the client from interacting and experiencing their remaining time should be minimized. Therefore, keeping the client comfortable without excessive sedation (C) is preferred. Allowing for some periods without medication (D) may be appropriate but should not compromise the client's comfort and pain control.

3. While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview?

Correct answer: C

Rationale: Choosing electronic documentation during an interview may hinder the nurse's ability to observe the client's nonverbal cues. Nonverbal communication, such as body language and facial expressions, plays a crucial role in understanding a client's feelings and needs. Focusing on entering data electronically may lead to missing important nonverbal cues that could provide valuable insights into the client's condition or emotions.

4. When performing sterile wound care in the acute care setting, the nurse obtains a bottle of normal saline from the bedside table that is labeled 'opened' and dated 48 hours prior to the current date. Which is the best action for the nurse to take?

Correct answer: D

Rationale: When performing sterile wound care, it is essential to use only newly opened and unexpired solutions to maintain sterility and prevent infections. The normal saline solution obtained by the nurse is labeled 'opened' and dated 48 hours prior to the current date, making it no longer considered sterile. The best action for the nurse to take in this situation is to discard the saline solution and obtain a new unopened bottle to ensure the safety and effectiveness of wound care. Choices A, B, and C are incorrect because reusing an already opened and outdated solution or attempting to relabel it with a current date can compromise patient safety and increase the risk of infection.

5. A client in a long-term care facility reports to the nurse that he has not had a bowel movement in 2 days. Which intervention should the nurse implement first?

Correct answer: C

Rationale: When a client reports a change in bowel habits, the first step for the nurse is to assess the client's normal bowel pattern by reviewing the medical records. This assessment helps the nurse understand the client's baseline, which is crucial before initiating any interventions. By determining the client's usual bowel habits, the nurse can identify deviations from the norm and make informed decisions on the appropriate course of action. Assessing the client's medical record is a critical first step in addressing the client's bowel concerns. Choices A, B, and D are incorrect because they jump to interventions without first establishing the client's normal bowel pattern. Offering warm prune juice, requesting a large-volume enema, or increasing fluids may not be appropriate until the nurse knows the client's regular bowel habits and can assess the situation effectively.

Similar Questions

During a home visit, an elderly female client who had a brain attack three months ago and can now ambulate with a quad cane is assessed by the nurse. Which assessment finding has the greatest implications for this client's care?
How should the nurse prepare the body of a deceased adult for transfer to the mortuary?
The healthcare provider is aware that malnutrition is a common problem among clients served by a community health clinic for the homeless. Which laboratory value is the most reliable indicator of chronic protein malnutrition?
When suctioning a tracheostomy, which action is most appropriate for the nurse to take?
A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago but feels fine now. What action is best for the nurse to take?

Access More Features

HESI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses