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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Palpation may alter bowel sounds, making auscultation after palpation less accurate.
B. Auscultation should be performed before percussion or palpation to prevent interference with the sounds.
C. Checking for kidney tenderness is important but does not affect the timing of auscultating bowel sounds.
D. Inspection should be done before auscultation to assess for any obvious abnormalities before listening for bowel sounds.
Correct Answer is B
Explanation
Pulse pressure is calculated as the difference between systolic and diastolic blood pressure. 170 - 90 = 80 mm Hg, so the pulse pressure would be 80mmHg.
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