1. A client who is unstable and requires frequent vital signs has an electronic blood pressure
machine automatically measuring his blood pressure every 15 min. However, the
machine is reading the client’s blood pressur
...
1. A client who is unstable and requires frequent vital signs has an electronic blood pressure
machine automatically measuring his blood pressure every 15 min. However, the
machine is reading the client’s blood pressure at more frequent intervals, and the readings
are not similar. The nurse checks the machine settings and observes the additional
readings, but the problem continues. Which of the following is the appropriate nursing
action?
--> Disconnect the machine, and measure the blood pressure manually every 15 min.
2. A nurse is caring for a client just diagnosed with type 1 diabetes mellitus. The client is
resistant to learning self-injection of insulin and asks the nurse to administer all the
injections. The nurse explains the importance of learning self-care and appropriately adds
which of the following statements?
Tell me what I can do to help you overcome your fear of giving yourself injections.
3. An assistive personnel says to the nurse, “This client is incontinent of stool three or four
times a day. I get angry, and I think that the client is doing it just to get attention. I think
we should put adult diapers on her.” Which is the appropriate nursing response?
2. A nurse is caring for a client who is scheduled to have his alanine aminotransferase (ALT)
level checked. The client asks the nurse to explain the laboratory test. Which of the following is
an appropriate response by the nurse?
a. “This test will indicate if you are at risk for developing blood clots
b. “This test will determine if your heart is performing properly”
c. “This test will provide information about the function of your liver”
Rationale: ALT test measures amount of enzyme in blood. ALT mainly found in liver
Rationale: Leadership 7.0. ALT and AST measure you liver function. Creatinine and BUN measure
your kidney function
d. “This test is used to check how your kidneys are working”
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