After a few hours in the emergency room, the client is admitted to the ward with an order of hourly monitoring of BP. The nurse finds that the cuff is too narrow and this will cause the BP reading to be:

Correct Answer: B

Rationale: The correct answer is B: Higher than what the reading should be. A narrow cuff will result in inaccurate BP readings because it can cause increased pressure on the artery, leading to artificially elevated readings. When the cuff is too narrow, it can compress the artery more than necessary, resulting in a higher BP reading. This is why it is important to use the correct cuff size based on the client's arm circumference to obtain an accurate reading. Choices A and C are incorrect because a narrow cuff would not result in a lower or the same BP reading, respectively. Choice D, inconsistent, is also incorrect because the incorrect cuff size will consistently produce higher readings due to increased pressure on the artery.

Correct Answer: A

Rationale: The correct answer is A: Upright leaning sideward. This position allows for better access to the pleural space between the ribs, minimizing the risk of injury to surrounding structures. The upright position helps to expand the lung and diaphragm, making it easier to locate the fluid pocket for thoracentesis. Leaning sideways helps to ensure gravity assists in pooling the fluid away from the needle insertion site. Choice B: Orthopneic is not the best position for thoracentesis as the patient is sitting upright and leaning forward, which may not be as effective in accessing the fluid pocket. Choice C: Prone position is incorrect because the patient is lying face down, making it difficult to access the pleural space in the back. Choice D: Supine position is also incorrect as the patient is lying flat on their back, making it challenging to access the pleural space effectively.

Correct Answer: C

Rationale: Correct Answer: C Rationale: 1. Forcing a tongue depressor between the teeth can cause injury during a seizure. 2. It is important to maintain a patent airway during a seizure. 3. Placing an object in the mouth can increase the risk of aspiration or damage to the teeth. 4. The nurse should protect the client from harm by ensuring a safe environment during a seizure. Summary: A: Not all seizures lead to status epilepticus; it depends on the individual. B: Oxygen may be needed, but it is not the priority over maintaining a clear airway. D: Administering anticonvulsant drugs is beneficial for seizure management.

Correct Answer: D

Rationale: The correct answer is D: Yellow trashcan. Wet adult diapers should be disposed of in the yellow trashcan designated for general waste. This is because soiled diapers are considered non-recyclable and non-hazardous waste. The yellow trashcan is typically used for general waste that cannot be recycled or composted. Placing the wet adult diaper in the green, black, or orange trashcan would be incorrect as these bins are usually designated for specific types of waste like recyclables, organic waste, or hazardous materials respectively. Proper disposal in the yellow trashcan ensures efficient waste management and prevents contamination of other waste streams.

Correct Answer: B

Rationale: The correct answer is B: Lower conjunctival sac. This is the correct site for administering eye drops in children. By placing the drops in the lower conjunctival sac, the medication can easily spread over the eye surface and be absorbed effectively. Placing the drops in the center of the cornea (choice A) can cause irritation and discomfort. Placing the drops on the sclera by the inner canthus (choice C) or outer canthus (choice D) may not allow proper absorption of the medication. Administering the drops in the lower conjunctival sac ensures maximum effectiveness and minimal discomfort for the child.