A nurse is checking the vital signs of a newly admitted patient who has a femur fracture. The patient's blood pressure is 140 / 94 mmHg. The client denies any history of hypertension. What should the nurse do next?

Correct Answer: A

Rationale: The patient has a broken femur and her blood pressure is elevated due to pain. The nurse should ask if she is having pain and continue a full pain assessment.

Correct Answer: C

Rationale: Licensure by the State Board of Nursing grants the legal authority to practice nursing.

Correct Answer: C

Rationale: The correct answer is C because isotonic solutions have a similar osmolarity to human blood, which helps maintain fluid balance without causing cell shrinkage or swelling. Normal saline 0.9% and ringers lactate are isotonic solutions commonly used in medical settings. Normal saline has a concentration of 0.9% sodium chloride, which closely matches the electrolyte composition of blood plasma. Ringers lactate contains electrolytes (sodium, potassium, calcium, and lactate) that closely mimic the body's extracellular fluid composition. Choice A (Normal saline 0.45%, dextrose 5%) is hypotonic because it has a lower osmolarity than blood, which can cause cells to swell. Choice B (Dextrose 50%, normal saline 0.45%) is hypertonic due to the high concentration of dextrose, which can draw water out of cells. Choice D (Aminosyn 3.5%, dextran

Correct Answer: A

Rationale: The correct answer is A: Call for help and note the time. This is the priority action because the client is unresponsive after a myocardial infarction, indicating a potential emergency situation. Calling for help ensures timely assistance and activates the emergency response team. Noting the time is crucial for accurate documentation and helps in determining the duration of unresponsiveness. Clearing the airway (B) and giving thumps to the precordium (C) are not appropriate without confirming the client's condition first. Checking the pulse (D) can be done after calling for help.

Correct Answer: C

Rationale: The correct answer is C: Clipping the hair in the area. This is the best option as it removes excess hair without the risk of causing microabrasions or skin irritation, which could increase the risk of infection. Clipping is less traumatic to the skin compared to shaving, which can cause microcuts. Leaving the hair intact can make it difficult to properly clean and maintain the site. Using a depilatory is not recommended as it can cause chemical irritation and is unnecessary for this purpose. Overall, clipping the hair in the area is the most appropriate and safe method for managing excess hair at an I.V. catheter insertion site.