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.
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Related Questions
Correct Answer is B
Explanation
A. Supine: Remaining in the supine position places prolonged pressure on the sacrum, heels, and occiput, increasing the risk for pressure ulcer development in patients who cannot reposition themselves.
B. Lateral: The lateral (side-lying) position redistributes pressure away from the sacrum and heels and is commonly used as part of a regular turning schedule to prevent pressure injuries.
C. Trendelenburg: This position increases pressure and shear forces on the sacral area and is not recommended for pressure ulcer prevention, especially for immobile patients.
D. Prone: While it offloads pressure from the back, the prone position is difficult to maintain, uncomfortable for most patients, and increases pressure on the face, chest, and knees.
Correct Answer is A
Explanation
A. Reduction in transcription errors due to illegible handwriting: CPOE allows providers to enter orders electronically, eliminating errors caused by unclear handwriting and misinterpretation. Standardized order sets and electronic transmission improve accuracy and patient safety. This is a well-established benefit of CPOE systems.
B. Reduction in alert fatigue because fewer prescriptions will be received: CPOE systems often include clinical decision support alerts, which can actually contribute to alert fatigue if not well managed. The volume of prescriptions is not reduced by CPOE. Alert fatigue is a recognized challenge rather than a benefit.
C. Increased dependency on technology during outages: Reliance on electronic systems during downtime can disrupt workflow and delay care. This represents a potential risk rather than an advantage. Downtime procedures are required to mitigate this issue.
D. Increase in workarounds due to system malfunctions: Workarounds may develop when systems are inefficient or malfunctioning, which can compromise safety. This outcome reflects poor system design or implementation. It is not a benefit of CPOE use.
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