A 45-year-old patient who is alert and oriented has a blood pressure of 98/66 mm Hg, radial pulse of 76 beats/min (irregular), and respirations of 18 breaths/min (regular). The best nursing intervention is to:

check the patient's record to determine his baseline blood pressure.

notify the charge nurse of the hypotension.

check medications that might be the cause of the irregularity.

notify the doctor of the bradycardia.

Answer and Explanation

The Correct Answer is A

A.   This is because the patient's blood pressure of 98/66 mm Hg, while on the lower side, may be normal for them. It's important to compare it to their baseline to determine if there has been a significant change.
B.   The blood pressure is within a normal range for an adult, so immediate notification of hypotension is not required.
C.   This can be done after determining if there is a significant change from the baseline.
D.   The pulse is not bradycardic (it is within a normal range), so there is no immediate need to notify the doctor regarding bradycardia.

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Correct Answer is D

Explanation

Rationale
A. Pumping the cuff until no sound is heard may cause inaccurate readings and is not a proper technique.
B. Stopping midway can result in missing sounds or causing an inaccurate measurement.

C. The bell of the stethoscope should be used for low-pitched sounds, but the key is to continue listening to identify the full Korotkoff sound range, especially in the presence of an auscultatory gap.
D. It is important to continue listening until the cuff is deflated to ensure the accurate measurement of both systolic and diastolic pressures, particularly in patients with an auscultatory gap.

A. measuring the oxygenated hemoglobin through a capillary bed. B. assessing the amount of blood passing through the sensor. C. assessing the relative warmth of the skin on the monitored part. D. measuring the respirations to the blood pressure via infrared rays.

Correct Answer is A

Explanation

A. Pulse oximetry works by using light absorption to measure the oxygen saturation of hemoglobin in the blood, which typically occurs through the capillary bed in areas like the finger or earlobe.
B. The pulse oximeter does not measure the amount of blood passing through the sensor directly, but rather the oxygen content of the blood.
C. The pulse oximeter does not assess the warmth of the skin as a mechanism for measuring oxygenation.
D. Pulse oximeters measure oxygen saturation levels, not the respiratory rate or blood pressure.

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A 45-year-old patient who is alert and oriented has a blood pressure of 98/66 mm Hg, radial pulse of 76 beats/min (irregular), and respirations of 18 breaths/min (regular). The best nursing intervention is to:

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Naxlex Comprehensive Predictor Exams

Older adult patients with hypertension may have an auscultatory gap in their Korotkoff sounds. It is important when taking their blood pressure measurement to:

Correct Answer is D

Explanation

The nurse explains to a patient that the pulse oximeter can measure the arterial oxygen by:

Correct Answer is A

Explanation

Because the older adult's blood vessels are nonelastic, they are prone to orthostatic hypotension. A priority intervention for a patient with orthostatic hypotension is to:

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A nurse is reinforcing teaching with the spouse of a client about how to take a blood pressure. Which of the following actions by the spouse indicates a need for further instruction?

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