A client has a prescription for vital sign measurement every four hours. The nurse observes that the client's blood pressure has increased from 140/60 mm Hg at noon to 180/90 mm Hg four hours later. Which action should the nurse implement?

Plan to measure the blood pressure in four hours as prescribed.

Repeat the client's blood pressure measurement in fifteen minutes.

Obtain an automatic blood pressure machine for hourly readings.

Reassess the blood pressure if the client reports other symptoms.

Answer and Explanation

The Correct Answer is B

A. Plan to measure the blood pressure in four hours as prescribed. Waiting for another four hours may not be appropriate given the significant increase in blood pressure. Immediate action is needed to address the elevated reading.

B. Repeat the client’s blood pressure measurement in fifteen minutes. This is the most appropriate action. When a client’s blood pressure is significantly elevated, it’s essential to recheck it promptly to confirm accuracy and assess for any changes. Fifteen minutes allows enough time for a follow-up measurement without unnecessary delay.

C. Obtain an automatic blood pressure machine for hourly readings. While continuous monitoring is valuable in some situations, it’s not necessary for routine blood pressure assessments. Hourly readings would be excessive and may not provide additional useful information.

D. Reassess the blood pressure if the client reports other symptoms. While assessing other symptoms is essential, waiting for symptoms to occur before reassessing blood pressure is not the best approach. Immediate follow-up is warranted based on the elevated reading alone

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Correct Answer is B

Explanation

A. Determine the client's most recent hemoglobin level: While low hemoglobin can be associated with conditions that cause clubbing, it's not the initial step. Documenting the finding is more important first.

B. Document the presence of nail bed clubbing: An angle of 200 degrees between the nail and nail bed is a classic sign of clubbing, which can be associated with various underlying conditions.

C. Administer a PRN prescription for oxygen: This is not indicated unless the client has respiratory problems, and clubbing itself doesn't necessitate oxygen.

D. Consult with a podiatrist: Consulting a podiatrist might be necessary for nail care in some situations, but it's not the most urgent action for nail bed clubbing. Documenting the finding and investigating the underlying cause is the priority.

A. Takes an oral anticoagulant. B. Works in a day care center. C. Adheres to a gluten free diet. D. Recently had dental surgery.

Correct Answer is A

Explanation

A. Takes an oral anticoagulant. Ecchymosis, or bruising, can be a side effect of anticoagulant therapy and may indicate potential bleeding issues that require further assessment.

B. Works in a day care centre. While exposure to children might increase the risk of minor injuries, it is less likely to be directly related to the ecchymosis observed.

C. Adheres to a gluten-free diet. This dietary preference is not likely to be directly related to the ecchymosis observed.

D. Recently had dental surgery. While recent surgery might be relevant, it is less likely to cause widespread ecchymosis unless there were complications.

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A client has a prescription for vital sign measurement every four hours. The nurse observes that the client's blood pressure has increased from 140/60 mm Hg at noon to 180/90 mm Hg four hours later. Which action should the nurse implement?

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Naxlex Comprehensive Predictor Exams

In assessing a client's nailbeds, the nurse notes that the angle between the nail and the nailbed is 200 degrees. Which action should the nurse take?

Correct Answer is B

Explanation

When inspecting the client's skin, the nurse observes several areas of ecchymosis on the trunk and extremities. Which information in the client's history requires additional follow-up by the nurse?

Correct Answer is A

Explanation

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