A patient is admitted to the telemetry unit with a diagnosis of cardiovascular disease
When performing the initial assessment, the nurse records blood pressure in the left arm of 142/84, blood pressure in the right arm of 138/80, temperature of 98.8° F, and radial pulse of 80 that is weak and irregular. The nurse should notify the physician regarding
a. both blood pressure and pulse.
b. blood pressure only.
c. pulse only.
d. both blood pressure and temperature.
ANS: C
Irregular pulse rate and rhythm should be reported. A systolic pressure variance of 5 to 10 mm Hg is normal; readings reflecting a variance of more than 10 mm Hg should be reported for further evaluation. Temperature is within normal limits.
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The nurse is evaluating the care received by a client who has a hearing deficit. Which client statement indicates that care has been effective?
A) "I ask others to face me when they talk, as I can hear them better." B) "I hear better when the television volume is raised." C) "I will change the battery in my hearing aid once a month." D) "I might use the hearing aid when I go shopping."
The client scheduled to have an intravenous urogram is a diabetic and taking the antidiabetic agent metformin. What should the nurse tell this client?
A. "Call your diabetes doctor and tell him or her that you are having an intravenous urogram performed using dye." B. "Do not take your metformin the morning of the test because you are not going to be eating anything and could become hypoglycemic." C. "You must start on an antibiotic before this test because your risk of infection is greater as a result of your diabetes." D. "You must take your metformin immediately before the test is performed because the IV fluid and the dye contain a significant amount of sugar."
Which question would be considered a "leading question?"
a. "What do you think is causing your head-aches?" b. "You don't get headaches often, do you?" c. "On a scale of 1 to 10, how would you rate the severity of your headaches?" d. "At what time of the day are your head-aches the most severe?"
Which of the following instructions is the most important for the nurse to give a client who is about to be discharged and has a surgical wound?
1. Adjust your diet so it contains more fruits and vegetables. 2. Apply lubricating lotion to the edges of the wound. 3. Notify your physician if you notice edema, heat, or tenderness at the wound site. 4. Thoroughly irrigate the wound with hydrogen peroxide.