Author Question: The nurse is preparing to assess blood pressure on the client. When the nurse enters the room, the ... (Read 113 times)

ENagel · **on:** Jul 22, 2018

The nurse is preparing to assess blood pressure on the client. When the nurse enters the room, the client is being assisted back to bed by the physical therapist following therapy. The nurse does which of the following?

1. Measures blood pressure quickly so the client can rest.
2. Waits for the therapist to get the client in bed and measure vital signs.
3. Requests permission from the client to measure vital signs.
4. Returns to measure vital signs in 10-15 minutes.

Question 2

The nurse is working in a neonatal intensive care unit and is caring for a baby born with myelomeningocele. The baby developed multiple infections, one of which resulted in removal of a large part of the bowel and creation of an ileostomy.

The baby was on the mechanical ventilator for several weeks, and developed bronchopulmonary dysplasia; he currently has a tracheostomy. The parents do not feel they are capable of caring for this child's multiple medical problems, because they both work outside the home and have four other children to care for. The nurse attends a client care conference and suggests placing the child in a: 1. Rehabilitation facility.
2. Long-term care facility.
3. Foster home.
4. Acute care facility.

Dunkey · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

4
Rationale: The client's blood pressure will be elevated after exercise, so the nurse should allow the client to rest and return in 10-15 minutes to measure blood pressure.

Answer to Question 2

2
Rationale: This client might benefit from placement in a pediatric long-term care facility that is capable of caring for an infant with multiple medical needs until the child's condition is stabilized enough to allow discharge to the home. The infant is too young to benefit from rehabilitation, although physical therapy will play an important role in this child's care. The parents' inability to provide skilled nursing care does not indicate a need to remove the child from their custody. The child is already in an acute care facility.