The nurse is taking the blood pressure on an infant. The priority action is to:
1. Avoid using the popliteal artery to get the BP.
2. Explain that you are taking the infant's blood pressure.
3. Use a cuff that covers two-thirds of surface involved.
4. Anticipate a higher blood pressure on a small child.
3
Rationale: Proper sizing of the blood pressure cuff is essential to an accurate reading, so the nurse should determine that two-thirds of the surface of the arm or leg is covered by the cuff.
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A client has been admitted from a nursing home for a workup to determine the cause of several recent falls. What intervention by the nurse takes priority?
a. Obtain a clean catch or catheterized urine specimen. b. Document the number of and causative factors for falls. c. Review the results of recent laboratory work for kidney function. d. Facilitate neurologic and social work consultations.
A nursing student states, "I can't stand using an index card for each day's planning. I like a monthly calendar so I can see the big picture." From this statement one can conclude that the student's time management strategies are most likely influenced by
a. a personal support system. b. the right cerebral hemisphere. c. corpus callosum crossover fibers. d. the left cerebral hemisphere
The client has been started on a treatment regimen that includes fosinopril (Monopril). The nurse realizes that the client has also been diagnosed with renal insufficiency. What is the most accurate nursing intervention?
a. Call the physician; the medication is contraindicated. b. Teach the client that the side effects of the drug will be intensified. c. Call the physician; the dosage will need to be decreased. d. Give the medication as ordered.
A nurse assesses a patient who takes lithium. Which findings demonstrate evidence of complications?
a. Pharyngitis, mydriasis, and dystonia b. Alopecia, purpura, and drowsiness c. Diaphoresis, weakness, and nausea d. Ascites, dyspnea, and edema