at a community health fair the blood pressure of a 62 year old client is 16096 mmhg the client states my blood pressure is usually much lower the nurs at a community health fair the blood pressure of a 62 year old client is 16096 mmhg the client states my blood pressure is usually much lower the nurs
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NCLEX RN Practice Questions With Rationale

1. At a community health fair, the blood pressure of a 62-year-old client is 160/96 mmHg. The client states, “My blood pressure is usually much lower.” The nurse should tell the client to:

Correct answer: Go get a blood pressure check within the next 15 minutes

Rationale: The blood pressure reading of 160/96 mmHg is moderately high, indicating hypertension. Given that the client mentions their blood pressure is usually lower, there is concern for acute complications like a stroke. Therefore, an immediate reassessment of the blood pressure within the next 15 minutes is warranted to confirm the reading and take appropriate actions if necessary. Waiting for two months (Choice B) or a week (Choice D) could pose risks of delaying intervention. Seeing the healthcare provider immediately (Choice C) is a good option, but in this case, the urgency is not as high as to require immediate attention at the healthcare provider's office.

2. The nurse is planning discharge instructions for the mother of a child following orchiopexy, which was performed on an outpatient basis. Which is a priority in the plan of care?

Correct answer: Wound care

Rationale: Following orchiopexy, the priority in the plan of care for the child's mother is wound care. The most common complications associated with orchiopexy are bleeding and infection. Discharge instructions should focus on demonstrating wound cleansing and dressing, and teaching parents to recognize signs of infection like redness, warmth, swelling, or discharge. It is crucial to prevent movement of the testicles and avoid contamination of the suture line. While analgesics may be prescribed, pain control measures are not the priority among the options presented. Measurement of intake is not essential as the child is likely to resume normal eating habits. Cold and heat applications are not typical prescribed treatments for post-orchiopexy care.

3. Which of the following tasks may be delegated to unlicensed assistive personnel?

Correct answer: Assisting with performing incentive spirometry

Rationale: Certain tasks can be safely delegated to unlicensed assistive personnel to assist nurses in their workload. Tasks that involve routine activities like incentive spirometry can be delegated. Unlicensed assistive personnel can assist clients with incentive spirometry, helping in promoting lung expansion and preventing respiratory complications. Cleansing a wound with peroxide (Choice A) and irrigating a colostomy (Choice B) involve more complex procedures that should be performed by licensed healthcare providers due to the risk of infection and potential complications. Removing a saline-lock IV (Choice D) requires specialized training and should only be performed by licensed personnel to prevent complications and ensure patient safety. The nurse remains responsible for delegating tasks appropriately and overseeing the care provided by unlicensed assistive personnel.

4. A patient is diagnosed with both human immunodeficiency virus (HIV) and active tuberculosis (TB) disease. Which information obtained by the nurse is most important to communicate to the healthcare provider?

Correct answer: The patient is receiving antiretroviral therapy for HIV infection.

Rationale: The most critical information to communicate to the healthcare provider in a patient diagnosed with both HIV and active TB disease is that the patient is receiving antiretroviral therapy for HIV infection. This is crucial because drug interactions can occur between antiretrovirals used to treat HIV infection and medications used to treat TB. By informing the healthcare provider about the antiretroviral therapy, potential interactions can be assessed and managed effectively to optimize patient care. The other data provided, such as the Mantoux test result, chest x-ray findings, and presence of blood-tinged mucus, are important clinical information but are expected in a patient with coexisting HIV and TB and do not directly impact potential drug interactions between antiretrovirals and TB medications.

5. An ambulatory client reports edema during the day in his feet and an ankle that disappears while sleeping at night. What is the most appropriate follow-up question for the nurse to ask?

Correct answer: Do you become short of breath during your normal daily activities?

Rationale: The correct answer is asking about shortness of breath during normal daily activities because these symptoms suggest right-sided heart failure, leading to increased pressure in the systemic venous system. This pressure causes fluid to shift into the interstitial spaces, resulting in edema. In an ambulatory patient, lower extremities are typically affected first due to gravity. By asking about shortness of breath, the nurse can gather information to confirm the nursing diagnosis of activity intolerance and fluid volume excess, both associated with right-sided heart failure. The other choices are less relevant in this context and do not directly address the client's presenting symptoms.

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