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 B

Explanation

A. Auscultating for bowel sounds once a shift is important but does not directly relate to the respiratory condition.
B. Auscultating lung sounds at the beginning of a shift is a priority to assess for any signs of respiratory compromise or complications.
C. Monitoring skin turgor every shift is important for hydration status but is less critical in comparison to lung sounds for a patient with respiratory problems.
D. Monitoring peripheral pulses once a shift is important but does not address the respiratory condition directly.

A. the eyes move in a normal coordinated manner. B. the pupils dilate when focusing on the object. C. there is blinking while trying to focus on the object. D. the pupils constrict focusing on the object.

Correct Answer is A

Explanation

A. Checking for normal, coordinated eye movement is key when assessing extraocular movements, which should be smooth and symmetric.
B. Pupillary dilation occurs under specific circumstances, such as low light, not necessarily when focusing on an object.
C. Blinking is a normal reflex but not a primary indicator when assessing extraocular movements.
D. Pupillary constriction is a separate function of the pupillary light reflex and not directly associated with extraocular movements.

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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

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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