A client presents with a blood pressure of 88/50 mmHg. Which nursing intervention is most appropriate?
Reassess blood pressure using a manual cuff and notify the provider.
Measure oxygen saturation to rule out hypoxia
Administer intravenous fluids to correct hypotension,
Position the client in a semi-Fowler's position to improve circulation.
The Correct Answer is A
A. Reassess blood pressure using a manual cuff and notify the provider: Confirming the reading ensures accuracy and rules out equipment error. Notifying the provider allows timely assessment and intervention for potential hypotensive complications, which is critical for patient safety.
B. Measure oxygen saturation to rule out hypoxia: While monitoring oxygenation is important, hypotension can exist independently of oxygen saturation. Addressing low blood pressure takes priority to prevent organ hypoperfusion.
C. Administer intravenous fluids to correct hypotension: Fluid resuscitation may be indicated, but the nurse should first verify the blood pressure reading and follow provider orders. Administering fluids without confirmation or orders could cause harm.
D. Position the client in a semi-Fowler's position to improve circulation: Semi-Fowler’s position may not optimize perfusion in hypotensive patients. Trendelenburg or supine positioning is typically more effective, but proper intervention requires provider guidance after assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Provide the requested items and document the client's cultural preference: Honoring cultural beliefs promotes client-centered care and supports trust in the nurse-client relationship. Providing herbal tea and warm soup aligns with the client’s cultural practices without causing harm, while documentation ensures continuity of care.
B. Offer cold beverages and suggest over-the-counter medications instead: Offering items that contradict the client’s cultural beliefs may cause distress or reduce adherence to care plans. Imposing standard remedies without consideration of cultural preferences undermines individualized care.
C. Explain that there is no scientific evidence supporting hot-cold balance and encourage standard remedies: While evidence-based care is important, dismissing cultural beliefs can damage rapport and discourage engagement. Cultural competence requires respectful integration of safe cultural practices with medical care.
D. Refer the client to a dietitian for nutritional counseling: Referral may be helpful for broader dietary concerns, but it is unnecessary solely to address cultural food requests related to acute symptoms. Immediate culturally appropriate interventions can be provided by the nurse.
Correct Answer is C
Explanation
A. Advise the client to avoid discussing the deceased with others: Avoiding discussion can intensify feelings of isolation and prevent processing of grief. Healthy grieving involves expressing emotions and sharing memories rather than suppressing them.
B. Encourage the client to focus on other areas of life to distract themselves: Distraction may provide temporary relief but does not address the underlying complicated grief. Encouraging avoidance of emotions can delay healing and exacerbate distress.
C. Refer the client to a bereavement counselor or therapist: Complicated grief involves prolonged, intense, or impairing symptoms that interfere with functioning. Referral to a mental health professional provides specialized assessment, support, and therapy to help the client process grief safely and effectively.
D. Suggest participating in daily physical exercise routines for emotional management: Physical activity can improve mood and reduce stress but is an adjunctive strategy. It does not replace professional intervention for complicated grief, which may require targeted psychotherapy or counseling.
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