. A nurse takes a patient’s blood pressure and records a diastolic pressure of 120 mm Hg. Which should the nurse do first? a. Notify the primary health-care provider. b. Retake the blood pressure. c. Notify the nurse in
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. A nurse takes a patient’s blood pressure and records a diastolic pressure of 120 mm Hg. Which should the nurse do first? a. Notify the primary health-care provider. b. Retake the blood pressure. c. Notify the nurse in charge. d. Take the other vital signs.
7. A patient had a stroke that resulted in paralysis of the right side. When clustering data, the nurse grouped the following together: drooling of saliva and slurred speech. Which information is most significant to include with this clustered data? a. Receptive aphasia b. Inability to ambulate c. Difficulty swallowing d. Incontinence of bowel movements
8. A patient who experienced a stroke has left-sided hemiparesis and is incontinent of urine. Which is an appropriately worded nursing diagnosis for this patient? a. The patient has a need to maintain skin integrity. b. The patient has a stroked evidenced by hemiparesis and incontinence. c. The patient will be clean and dry and will receive range-of-motion exercises every four hours. d. The patient is at risk for impaired skin integrity related to left-sided hemiparesis and incontinence.
9. A nurse uses the interviewing process of clarification when interviewing a patient. Which is the nurse doing when this communication technique is used? a. Paraphrasing the patient’s message b. Restating what the patient has said c. Reviewing the patient’s communication d. Verifying what is implied by the patient
10.A patient has dependent edema of the ankles and feet and is obese. Which diet should the nurse expect the primary health-care provider to order? a. Low in sodium and high in fat b. Low in sodium and low in calories c. High in sodium and high in protein d. High in sodium and low in carbohydrates
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