EXAM #2 PREP QUESTION PDF

1. Medication Administration and the Six Rights 1. A nurse is preparing to administer medication to a patient. Which action ensures the "right patient" is followed? a. Ask the patient to state their name. b. Verify the patient’s name and date of birth. c. Check the pa...

1. Medication Administration and the Six Rights 1. A nurse is preparing to administer medication to a patient. Which action ensures the "right patient" is followed? a. Ask the patient to state their name. b. Verify the patient’s name and date of birth. c. Check the patient’s room number. d. Confirm the medication with the prescribe Answer: b. Verify the patient’s name and date of birth. Rationale: The nurse must use two patient identifiers (e.g., name and date of birth) to ensu the right patient receives the medication. Room numbers are not reliable identifier 2. Which action by the nurse ensures the "right dose" of medication is administered? a. Calculate the dose independently. b. Use a standardized dosing chart. c. Double-check calculations with another nurse. d. Ask the patient if the dose seems correct. Answer: c. Double-check calculations with another nurse. Rationale: High-risk medications require independent double-checking to prevent dosing errors. 3. A nurse is administering a sublingual medication. What instruction should the nurse provide to the patient? a. "Chew the medication thoroughly." b. "Place the medication under your tongue and let it dissolve." c. "Swallow the medication with water." d. "Hold the medication in your cheek pouch." Answer: b. "Place the medication under your tongue and let it dissolve." Rationale: Sublingual medications are absorbed through the mucous membranes under the tongue for rapid systemic effect. 4. Which action by the nurse ensures the "right route" of medication administration? a. Administer the medication as prescribed. b. Ask the patient their preferred route. c. Change the route if the patient refuses. d. Administer all medications orally. Answer: a. Administer the medication as prescribed. Rationale: The route of administration is determined by the prescriber based on the drug’s pharmacokinetics and the patient’s condition.  5. A nurse is preparing to administer a topical medication. What action should the nurse take? a. Apply the medication to wet skin. b. Use sterile gloves for application. c. Rub the medication into the skin vigorously. d. Apply the medication to clean, dry skin. Answer: d. Apply the medication to clean, dry skin. Rationale: Topical medications are most effective when applied to clean, dry skin to ensure proper absorption. 2. Injection Techniques and Landmarks 6. A nurse is preparing to administer an intramuscular (IM) injection to an adult. Which site is most appropriate? a. Deltoid b. Vastus lateralis c. Ventrogluteal d. Dorsogluteal Answer: c. Ventrogluteal Rationale: The ventrogluteal site is preferred for IM injections in adults because it has fewer blood vessels and nerves, reducing the risk of complications. 7. A nurse is administering a subcutaneous (SubQ) injection. Which needle size is most appropriate? a. 1.5 inches, 22 gauge b. 5/8 inch, 25 gauge c. 1 inch, 18 gauge d. 3/8 inch, 27 gauge Answer: b. 5/8 inch, 25 gauge Rationale: SubQ injections require a shorter needle (5/8 inch) and smaller gauge (25–30) to ensure the medication is deposited in the subcutaneous tissue. 8. A nurse is preparing to administer an intradermal (ID) injection. What angle should the nurse use? a. 10–15 degrees b. 45 degrees c. 90 degrees d. 30 degrees Answer: a. 10–15 degrees Rationale: ID injections are administered at a shallow angle to ensure the medication is  deposited in the dermis. 9. A nurse is administering an IM injection to an infant. Which site is most appropriate? a. Deltoid b. Vastus lateralis c. Ventrogluteal d. Dorsogluteal Answer: b. Vastus lateralis Rationale: The vastus lateralis is the preferred site for IM injections in infants because it is well-developed and free of major blood vessels and nerves. 10. A nurse is preparing to administer a Z-track IM injection. What is the purpose of this technique? a. To reduce pain b. To prevent leakage into subcutaneous tissue c. To increase absorption d. To minimize bleeding Answer: b. To prevent leakage into subcutaneous tissue Rationale: The Z-track technique is used for IM injections to prevent medication from leaking into the subcutaneous tissue, which can cause irritation. 3. Medication Administration and Patient Safety 11. A nurse is reviewing a medication order. Which action should the nurse take if the order is unclear? a. Administer the medication as written. b. Clarify the order with the prescriber. c. Ask the patient about the medication. d. Skip the medication and document it. Answer: b. Clarify the order with the prescriber. Rationale: The nurse must clarify any unclear or incomplete medication orders to ensure patient safety. 12. A nurse is preparing to administer a medication that requires peak and trough levels. What is the purpose of monitoring these levels? a. To assess the patient’s hydration status b. To evaluate the medication’s effectiveness and toxicity c. To determine the patient’s renal function  d. To monitor the patient’s blood pressure Answer: b. To evaluate the medication’s effectiveness and toxicity Rationale: Peak and trough levels are used to monitor the therapeutic range of medications, such as antibiotics, to ensure effectiveness and prevent toxicity. 13. A nurse is administering a medication via a nebulizer. What instruction should the nurse provide to the patient? a. "Breathe rapidly through your mouth." b. "Hold your breath after inhaling the medication." c. "Breathe normally through the mouthpiece." d. "Exhale forcefully after each breath." Answer: c. "Breathe normally through the mouthpiece." Rationale: Nebulizers deliver medication as a fine mist, and the patient should breat normally to ensure proper delivery to the lungs. 14. A nurse is preparing to administer an ear irrigation. What action should the nurse take? a. Use cold water for the irrigation. b. Position the patient’s head tilted toward the affected ear. c. Use sterile technique for the procedure. d. Apply pressure to the ear canal after irrigation. Answer: c. Use sterile technique for the procedure. Rationale: Ear irrigations require sterile technique to prevent infection. 15. A nurse is administering a medication to a patient with dysphagia. Which route is most appropriate? a. Oral b. Sublingual c. Buccal d. Nasogastric tube Answer: d. Nasogastric tube Rationale: Patients with dysphagia may require medications to be administered via a nasogastric tube to ensure safe delivery. 4. Pharmacology and Physiology 16. A nurse is administering a sublingual nitroglycerin tablet to a patient with chest pain. What is the rationale for this route? a. It avoids first-pass metabolis  b. It provides sustained release of the medication. c. It reduces gastrointestinal side effects. d. It increases the medication’s half-life. Answer: a. It avoids first-pass metabolis Rationale: Sublingual medications bypass the liver and enter the bloodstream directly, providing rapid systemic effects. 17. A nurse is administering an IM injection of a vaccine. What is the primary site of action for vaccines? a. Liver b. Lymphatic system c. Kidneys d. Gastrointestinal tract Answer: b. Lymphatic system Rationale: Vaccines stimulate the immune system, which is primarily mediated by the lymphatic system. 18. A nurse is administering a medication that is metabolized by the liver. Which laboratory value should the nurse monitor? a. Serum creatinine b. Alanine aminotransferase (ALT) c. Hemoglobin d. White blood cell count Answer: b. Alanine aminotransferase (ALT) Rationale: ALT is a liver enzyme that indicates liver function. Elevated levels may suggest liver damage. 19. A nurse is administering a medication that is excreted by the kidneys. Which laboratory value should the nurse monitor? a. Serum creatinine b. Alanine aminotransferase (ALT) c. Hemoglobin d. White blood cell count Answer: a. Serum creatinine Rationale: Serum creatinine is a marker of kidney function. Elevated levels may indicate impaired renal excretion. 20. A nurse is administering a medication that causes vasodilation. What is the expected  physiological response? a. Increased blood pressure b. Decreased heart rate c. Increased peripheral blood fl d. Decreased respiratory rate Answer: c. Increased peripheral blood fl Rationale: Vasodilation relaxes blood vessels, increasing peripheral blood flow and reduci blood pressure. 5. Patient Education and Communication 21. A nurse is teaching a patient about the use of a metered-dose inhaler (MDI). What instruction should the nurse provide? a. "Inhale rapidly after activating the inhaler." b. "Hold your breath for 10 seconds after inhaling." c. "Exhale forcefully after using the inhaler." d. "Shake the inhaler only if it contains a steroid." Answer: b. "Hold your breath for 10 seconds after inhaling." Rationale: Holding the breath allows the medication to deposit in the lungs for maximum effectiveness. 22. A nurse is teaching a patient about the use of a transdermal patch. What instruction should the nurse provide? a. "Apply the patch to the same site every time." b. "Remove the old patch before applying a new one." c. "Apply the patch to hairy skin for better adhesion." d. "Leave the patch on for 48 hours after the medication is depleted." Answer: b. "Remove the old patch before applying a new one." Rationale: Leaving an old patch on can lead to overdose or skin irritation. 23. A nurse is teaching a patient about the use of eye drops. What instruction should the nurse provide? a. "Tilt your head forward after instilling the drops." b. "Blink rapidly after instilling the drops." c. "Apply pressure to the inner canthus after instilling the drops." d. "Rub your eyes gently after instilling the drops." Answer: c. "Apply pressure to the inner canthus after instilling the drops." Rationale: Applying pressure to the inner canthus prevents systemic absorption of the medication.  24. A nurse is teaching a patient about the use of a buccal medication. What instruction should the nurse provide? a. "Chew the medication thoroughly." b. "Place the medication between your cheek and gum." c. "Swallow the medication with water." d. "Hold the medication on your tongue." Answer: b. "Place the medication between your cheek and gum." Rationale: Buccal medications are absorbed through the mucous membranes of the cheek. 25. A nurse is teaching a patient about the use of a topical corticosteroid. What instruction should the nurse provide? a. "Apply a thick layer of the medication." b. "Cover the area with an occlusive dressing." c. "Wash the area with soap and water before application." d. "Apply the medication to clean, dry skin." Answer: d. "Apply the medication to clean, dry skin." Rationale: Topical corticosteroids are most effective when applied to clean, dry skin. 6. Special Considerations 26. A nurse is administering a medication to an elderly patient. What consideration should the nurse keep in mind? a. Elderly patients require higher doses due to decreased metabolism. b. Elderly patients are at increased risk for adverse drug reactions. c. Elderly patients absorb medications more quickly. d. Elderly patients have increased renal excretion. Answer: b. Elderly patients are at increased risk for adverse drug reactions. Rationale: Age-related changes in metabolism, absorption, and excretion increase the risk of adverse effects in elderly patients. 27. A nurse is administering a medication to a pediatric patient. What consideration should the nurse keep in mind? a. Pediatric patients require higher doses due to faster metabolism. b. Pediatric patients are at increased risk for medication errors. c. Pediatric patients absorb medications more slowly. d. Pediatric patients have decreased renal excretion. Answer: b. Pediatric patients are at increased risk for medication errors. Rationale: Pediatric patients require weight-based dosing, and miscalculations can lead to errors.  28. A nurse is administering a medication to a pregnant patient. What consideration should the nurse keep in mind? a. Pregnant patients require higher doses due to increased blood volume. b. Pregnant patients are at increased risk for teratogenic effects. c. Pregnant patients absorb medications more quickly. d. Pregnant patients have increased renal excretion. Answer: b. Pregnant patients are at increased risk for teratogenic effects. Rationale: Medications can cross the placenta and harm the developing fetus. 29. A nurse is administering a medication to a breastfeeding patient. What consideration should the nurse keep in mind? a. Medications can be excreted in breast milk. b. Breastfeeding patients require lower doses of medications. c. Medications are not absorbed during lactation. d. Breastfeeding patients have increased renal excretion. Answer: a. Medications can be excreted in breast milk. Rationale: Medications taken by the mother can pass into breast milk and affect the infant. 30. A nurse is administering a medication to a patient with renal impairment. What consideration should the nurse keep in mind? a. The patient may require higher doses of the medication. b. The patient may require a longer dosing interval. c. The patient may absorb medications more quickly. d. The patient may have increased hepatic metabolism. Answer: b. The patient may require a longer dosing interval. Rationale: Renal impairment reduces the excretion of medications, increasing the risk of toxicity. Adjustments in dosing intervals may be necessary. 1. Physiological Effects of Immobility 1. A nurse is caring for an immobile client. Which complication is the client at greatest risk for? a. Hypertension b. Deep vein thrombosis (DVT) c. Hyperglycemia d. Diarrhea Answer: b. Deep vein thrombosis (DVT) Rationale: Immobility increases the risk of DVT due to venous stasis. 2. Which respiratory complication is most common in immobile clients? a. Asthma  b. Pneumonia c. Pulmonary embolism d. Chronic obstructive pulmonary disease (COPD) Answer: b. Pneumonia Rationale: Immobility leads to stasis of secretions, increasing the risk of pneumonia. 3. A nurse is assessing an immobile client. Which finding indicates a potenti complication of immobility? a. Increased urine output b. Warm, reddened calf c. Hyperactive bowel sounds d. Decreased respiratory rate Answer: b. Warm, reddened calf Rationale: This may indicate DVT, a common complication of immobility. 4. Which intervention is most effective in preventing pressure ulcers in an immobile client? a. Administering antibiotics b. Repositioning every 2 hours c. Applying heat to pressure points d. Massaging bony prominences Answer: b. Repositioning every 2 hours Rationale: Frequent repositioning relieves pressure and prevents skin breakdown. 5. A nurse is caring for an immobile client. Which intervention is most important to prevent constipation? a. Encouraging fluid inta b. Administering laxatives daily c. Restricting fiber inta d. Limiting physical activity Answer: a. Encouraging fluid inta Rationale: Adequate hydration helps prevent constipation in immobile clients. 2. Range of Motion (ROM) Exercises 6. A nurse is teaching a client about active ROM exercises. Which statement by the client indicates understanding? a. "I will move my joints myself." b. "I will need someone to move my joints for me." c. "I will avoid moving my joints to prevent pain."  d. "I will only move my joints once a week." Answer: a. "I will move my joints myself." Rationale: Active ROM exercises are performed by the client independently. 7. A nurse is performing passive ROM exercises for a client. Which action is correct? a. Ask the client to move their joints. b. Move the client’s joints through their full range. c. Avoid moving the client’s joints past the point of resistance. d. Perform ROM exercises once a week. Answer: b. Move the client’s joints through their full range. Rationale: Passive ROM exercises are performed by the nurse moving the client’s joints. 8. Which joint movement is included in ROM exercises? a. Flexion b. Compression c. Immobilization d. Extension Answer: a. Flexion Rationale: Flexion is a common joint movement included in ROM exercises. 3. Body Mechanics 9. A nurse is teaching a client about proper body mechanics. Which instruction is correct? a. "Bend at the waist when lifting objects." b. "Keep your feet close together when lifting." c. "Use your back muscles to lift heavy objects." d. "Bend at the knees and keep your back straight." Answer: d. "Bend at the knees and keep your back straight." Rationale: Proper body mechanics involve bending at the knees and keeping the back straight to prevent injury. 10.A nurse is transferring a client from the bed to a wheelchair. Which action is most important? a. Lock the wheelchair brakes. b. Position the wheelchair at a 45-degree angle to the bed. c. Lift the client without assistance. d. Avoid using a gait belt. Answer: a. Lock the wheelchair brakes.  Rationale: Locking the brakes ensures the wheelchair does not move during the transfer. 4. Assistive Devices 11.A nurse is teaching a client how to use a cane. Which instruction is correct? a. "Hold the cane on the unaffected side." b. "Move the cane and the affected leg together." c. "Use the cane for support on the affected side." d. "Place the cane 12 inches in front of you when walking." Answer: a. "Hold the cane on the unaffected side." Rationale: The cane is held on the unaffected side to provide support and balance. 12.A nurse is teaching a client how to use a walker. Which instruction is correct? a. "Lift the walker and move it forward." b. "Slide the walker forward while walking." c. "Place the walker 2 feet in front of you." d. "Use the walker on stairs." Answer: a. "Lift the walker and move it forward." Rationale: Walkers should be lifted and moved forward to ensure stability. 5. Client/Caregiver Education 13.A nurse is teaching a caregiver about ROM exercises. Which statement by the caregiver indicates understanding? a. "I will perform ROM exercises once a week." b. "I will move the joints past the point of resistance." c. "I will perform ROM exercises daily." d. "I will avoid moving the joints to prevent pain." Answer: c. "I will perform ROM exercises daily." Rationale: ROM exercises should be performed daily to maintain joint mobility. 14.A nurse is teaching a client about proper body mechanics. Which instruction is correct? a. "Bend at the waist when lifting objects." b. "Keep your feet close together when lifting." c. "Use your back muscles to lift heavy objects." d. "Bend at the knees and keep your back straight." Answer: d. "Bend at the knees and keep your back straight." Rationale: Proper body mechanics involve bending at the knees and keeping the back straight to prevent injury. 5. Complications of Immobility 15.A nurse notes a red, non-blanchable area over a client’s sacrum. What stage pressure ulcer is this? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4 Answer: a. Stage 1 Rationale: Stage 1 pressure ulcers present as intact, non-blanchable redness without skin breakdown. 16.Which assessment finding indicates a risk for developing orthostat hypotension in an immobile client? a. Bradycardia b. Drop in blood pressure when standing c. Increased urine output d. Hyperactive bowel sounds Answer: b. Drop in blood pressure when standing Rationale: Orthostatic hypotension is a drop in BP ≥20 mmHg systolic or ≥10 mmHg diastolic when moving from lying to standing. 17.A nurse assesses a positive Homans’ sign in an immobile client. What complication is suspected? a. Pneumonia b. Deep vein thrombosis (DVT) c. Urinary retention d. Pressure ulcer Answer: b. Deep vein thrombosis (DVT) Rationale: Homans’ sign (calf pain on dorsiflexion) may indicate DVT, though it not definitiv 18.Which intervention is most effective to prevent urinary stasis in an immobile client? a. Restrict fluid inta b. Insert a Foley catheter c. Encourage frequent toileting d. Administer diuretics  Answer: c. Encourage frequent toileting Rationale: Regular bladder emptying reduces the risk of urinary stasis and infection. 19.A client with prolonged immobility develops hypercalcemia. Which complication is most likely? a. Renal calculi b. Hypoglycemia c. Muscle hypertrophy d. Hypertension Answer: a. Renal calculi Rationale: Immobility causes bone resorption, releasing calcium into the bloodstream, increasing the risk of kidney stones. 6. Nursing Interventions 20.A nurse is caring for an immobile client. Which intervention reduces the risk of atelectasis? a. Compression stockings b. Incentive spirometry c. TED hose d. Range of motion exercises Answer: b. Incentive spirometry Rationale: Incentive spirometry promotes lung expansion and prevents alveolar collapse. 21.Which action by the nurse prevents foot drop in an immobile client? a. Apply wrist splints b. Use a footboard c. Massage the feet d. Elevate the legs Answer: b. Use a footboard Rationale: A footboard maintains dorsiflexion, preventing foot dro 22.A nurse is repositioning a client every 2 hours. Which position is most effective for preventing pressure ulcers? a. Supine  b. Prone c. 30-degree lateral tilt d. High Fowler’s Answer: c. 30-degree lateral tilt Rationale: A 30-degree lateral tilt reduces pressure on bony prominences. 23.Which dietary recommendation should the nurse provide to an immobile client with constipation? a. Low-fiber di b. Increased protein intake c. High-fiber diet and fl d. Restricted flui Answer: c. High-fiber diet and fl Rationale: Fiber and hydration promote bowel motility. 24.A nurse is applying compression stockings to a client. What is the primary purpose? a. Prevent muscle atrophy b. Reduce edema c. Prevent DVT d. Treat pressure ulcers Answer: c. Prevent DVT Rationale: Compression stockings improve venous return, reducing DVT risk. 7. Assistive Devices 25.A client using a walker complains of wrist pain. What is the most likely cause? a. The walker is too short b. The walker is too tall c. The client is leaning forward d. The client is using a four-point gait Answer: b. The walker is too tall Rationale: Incorrect walker height (too tall) forces the client to elevate their shoulders, causing wrist strain. 26.A nurse is teaching a client to use crutches. Which instruction is correct for a three-point gait? a. “Move both crutches and the affected leg together.”  b. “Move the crutches first, then the unaffected leg c. “Move the unaffected leg first, then the crutches d. “Move the crutches and both legs together.” Answer: a. “Move both crutches and the affected leg together.” Rationale: Three-point gait is used when one leg is non-weight-bearing. 27.Which assistive device provides the most stability for a client with bilateral leg weakness? a. Cane b. Walker c. Crutches d. Wheelchair Answer: b. Walker Rationale: Walkers provide a wide base of support and stability. 28.A nurse is adjusting a client’s cane. At which anatomical landmark should the handle align? a. Wrist crease b. Elbow c. Hip d. Shoulder Answer: a. Wrist crease Rationale: The cane handle should align with the wrist crease when the arm is relaxed. 8. Caregiver Education 29.A caregiver asks, “How often should I reposition my immobile family member?” What is the nurse’s best response? a. “Every 4 hours.” b. “Every 2 hours.” c. “Once a day.” d. “Only when they complain of pain.” Answer: b. “Every 2 hours.” Rationale: Repositioning every 2 hours prevents pressure ulcers. 30.A nurse is teaching a caregiver about passive ROM exercises. Which action is  correct? a. Ask the client to move their own joints. b. Move the client’s joints through their full range. c. Avoid moving joints past resistance. d. Perform ROM exercises once weekly. Answer: b. Move the client’s joints through their full range. Rationale: Passive ROM requires the caregiver to move the client’s joints. 31.Which instruction should the nurse provide to a caregiver transferring a client from bed to chair? a. “Stand on the client’s weak side.” b. “Use a gait belt around the client’s waist.” c. “Lift the client under their arms.” d. “Avoid locking the wheelchair brakes.” Answer: b. “Use a gait belt around the client’s waist.” Rationale: A gait belt ensures safe handling and reduces caregiver injury risk. 9. Special Populations 32.An elderly immobile client is at risk for osteoporosis. Which intervention is most effective? a. Restrict calcium intake b. Encourage weight-bearing exercises c. Administer sedatives d. Limit fluid intake Answer: b. Encourage weight-bearing exercises Rationale: Weight-bearing exercises stimulate bone density maintenance. 33.A pediatric client with immobility is at risk for developmental delays. Which intervention is most important? a. Restrict playtime b. Encourage age-appropriate activities c. Limit social interaction d. Avoid physical therapy Answer: b. Encourage age-appropriate activities Rationale: Play and activities promote motor and cognitive development.  34.A pregnant client on bed rest is at risk for DVT. Which intervention is most appropriate? a. Apply compression stockings b. Restrict fluid inta c. Encourage crossing the legs d. Avoid ROM exercises Answer: a. Apply compression stockings Rationale: Compression stockings improve venous return and reduce DVT risk. 10. Documentation & Evaluation 35.A nurse documents “client tolerated ambulation with walker for 10 feet without dizziness.” Which part of the nursing process does this address? a. Assessment b. Diagnosis c. Implementation d. Evaluation Answer: d. Evaluation Rationale: Evaluation involves assessing the client’s response to interventions. 36.Which statement by a client using a walker indicates effective teaching? a. “I’ll slide the walker forward while walking.” b. “I’ll lift the walker and move it forward.” c. “I’ll place the walker behind me.” d. “I’ll use the walker on stairs.” Answer: b. “I’ll lift the walker and move it forward.” Rationale: Walkers should be lifted, not slid, to maintain stability. 11. Advanced Complications 37.A client with immobility develops sudden dyspnea and chest pain. What complication should the nurse suspect? a. Pneumonia b. Pulmonary embolism c. Urinary retention d. Constipation  Answer: b. Pulmonary embolism Rationale: Sudden dyspnea and chest pain may indicate PE, a life-threatening complication of DVT. 38.A nurse assesses pitting edema in an immobile client’s lower extremities. What is the priority intervention? a. Elevate the legs b. Massage the calves c. Apply heat d. Restrict flui Answer: a. Elevate the legs Rationale: Elevation promotes venous return and reduces edema. 12. Psychosocial Considerations 39.An immobile client reports feeling depressed. Which intervention is most appropriate? a. Ignore the client’s feelings b. Encourage socialization and activities c. Restrict visitors d. Administer sedatives Answer: b. Encourage socialization and activities Rationale: Social interaction and engagement reduce feelings of isolation and depression. 40.A nurse is caring for a client with prolonged immobility. Which intervention addresses the client’s risk for sensory deprivation? a. Provide a quiet, dark room b. Encourage television and reading c. Restrict family visits d. Avoid conversation Answer: b. Encourage television and reading Rationale: Sensory stimulation (e.g., TV, reading) prevents sensory deprivation. 1. Vital Sign Assessment  1. A nurse is assessing an adult client’s apical pulse. For how long should the nurse count the heartbeat? a. 15 seconds b. 30 seconds c. 60 seconds d. 10 seconds Answer: c. 60 seconds Rationale: The apical pulse is counted for a full minute to detect irregularities. 2. Which site is most appropriate for measuring temperature in a toddler? a. Rectal b. Axillary c. Tympanic d. Oral Answer: c. Tympanic Rationale: Tympanic is safe and non-invasive for toddlers. 2. Abnormal Vital Signs 3. A client has a blood pressure of 150/95 mmHg. How should the nurse classify this findin a. Hypotension b. Stage 1 hypertension c. Stage 2 hypertension d. Hypertensive crisis Answer: b. Stage 1 hypertension Rationale: Stage 1 hypertension: Systolic 130–139 or diastolic 80–89 mmHg. 4. A client’s SpO₂ is 88%. What action should the nurse take firs a. Administer oxygen b. Notify the provider c. Recheck with a different probe d. Elevate the head of the bed Answer: a. Administer oxygen Rationale: SpO₂