A client who receives an antihypertensive medication daily is NPO except medications for surgery. The most recent blood pressure recording is 174/88. What action should the nurse take first?

Notify the surgeon of the blood pressure.

Document the blood pressure on the pre-op checklist.

Have the client relax and take deep breaths.

Administer the antihypertensive medication.

Answer and Explanation

The Correct Answer is D

Choice A Reason:

Notifying the surgeon of the blood pressure is important, but it is not the first action the nurse should take. The primary concern is to manage the patient’s high blood pressure to prevent any complications during surgery. Once the blood pressure is under control, the nurse can then notify the surgeon if necessary.

Choice B Reason:

Documenting the blood pressure on the pre-op checklist is a necessary step, but it is not the immediate priority. The nurse’s first action should be to address the elevated blood pressure to ensure the patient’s safety. Documentation can be done after the immediate concern is managed.

Choice C Reason:

Having the client relax and take deep breaths can help lower blood pressure temporarily, but it is not a sufficient intervention for a blood pressure reading as high as 174/88. The nurse should take a more direct approach to manage the hypertension, such as administering the prescribed antihypertensive medication.

Choice D Reason:

Administering the antihypertensive medication is the most appropriate first action. The patient is NPO (nothing by mouth) except for medications, indicating that the medication should still be given. This action directly addresses the elevated blood pressure and helps to stabilize the patient before surgery.

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Correct Answer is B

Explanation

Choice A reason: Lung sounds being clear bilaterally, both anterior and posterior, is a positive sign and indicates that there are no immediate obstructions or significant inflammation in the airways. However, it does not provide a comprehensive measure of asthma control over time. Asthma control is better assessed through objective measures like peak expiratory flow rate (PEFR) readings.

Choice B reason: Peak expiratory flow rate (PEFR) readings in the green zone indicate that the client’s asthma is well-controlled. The green zone typically represents 80-100% of the client’s personal best PEFR, suggesting that their airways are open and they are not experiencing significant bronchoconstriction. Regular monitoring of PEFR helps in assessing the effectiveness of the asthma management plan and making necessary adjustments to prevent exacerbations.

Choice C reason: Reporting shortness of breath when engaging in exercise suggests that the client’s asthma may not be fully controlled. Exercise-induced bronchoconstriction is a common issue in asthma, and experiencing symptoms during physical activity indicates that the current medication regimen may need adjustment.

Choice D reason: Having three occurrences of asthma exacerbations in the past month indicates poor asthma control. Frequent exacerbations suggest that the client’s asthma is not well-managed and that their medication regimen may need to be reviewed and adjusted.

A. Sputum culture of Mycobacterium tuberculosis B. Tuberculin (PPD) skin test C. Acid-fast bacillus smear D. Chest X-ray

Correct Answer is A

Explanation

Choice A reason:

A sputum culture of Mycobacterium tuberculosis is the definitive test for diagnosing tuberculosis (TB). This test involves collecting a sputum sample and culturing it to detect the presence of Mycobacterium tuberculosis, the bacteria that cause TB. It is considered the gold standard for confirming active TB infection.

Choice B reason:

The Tuberculin (PPD) skin test, also known as the Mantoux test, is used to screen for TB infection. It can indicate whether a person has been exposed to TB bacteria, but it cannot confirm active TB disease. A positive result requires further testing, such as a sputum culture, to confirm the diagnosis.

Choice C reason:

An acid-fast bacillus (AFB) smear is a quick test that can detect the presence of mycobacteria in a sputum sample. While it can provide a preliminary indication of TB, it is not definitive. A positive AFB smear must be followed by a sputum culture to confirm the diagnosis.

Choice D reason:

A chest X-ray can show abnormalities in the lungs that are suggestive of TB, such as cavities or infiltrates. However, it cannot confirm the diagnosis on its own. Chest X-rays are used in conjunction with other tests, such as sputum culture and AFB smear, to diagnose TB.

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A client who receives an antihypertensive medication daily is NPO except medications for surgery. The most recent blood pressure recording is 174/88. What action should the nurse take first?

Nursing Test Bank

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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