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A group of student nurses are practicing taking blood pressures. A 56-year-old male student has a blood pressure reading of 146/96 mm Hg. Upon hearing the reading, he exclaims, “My pressure has never been this high. Do you think my doctor will prescribe medication to reduce it?” Which of the following responses by the nursing instructor would be best?

“A single elevated blood pressure does not confirm hypertension. A diagnosis of hypertension requires two or more elevated readings taken by your physician before a diagnosis can be made.”

“We will need to reevaluate your blood pressure because your age places you at high risk for hypertension.”

“Hypertension is prevalent among men: it is fortunate we caught this during your routine examination.”

“You have no need to worry. Your pressure is probably elevated because you are being tested.”

Answer and Explanation

The Correct Answer is A

A. "A single elevated blood pressure does not confirm hypertension. A diagnosis of hypertension requires two or more elevated readings taken by your physician before a diagnosis can be made."

This response emphasizes the need for multiple elevated readings for a diagnosis of hypertension. It educates the individual about the diagnostic criteria and encourages them to seek further evaluation from their physician.

B. "We will need to reevaluate your blood pressure because your age places you at high risk for hypertension."

This response might be seen as implying that age alone is a significant factor in determining hypertension, which may not be accurate. While age is a risk factor, the emphasis should be on the need for multiple readings and a physician's evaluation rather than attributing it solely to age.

C. "Hypertension is prevalent among men: it is fortunate we caught this during your routine examination."

This response suggests that the elevated blood pressure is automatically assumed to be hypertension based on gender. It is important to avoid making assumptions and instead focus on the need for proper evaluation and multiple readings for a hypertension diagnosis.

D. "You have no need to worry. Your pressure is probably elevated because you are being tested."

This response dismisses the individual's concerns and attributes the elevated blood pressure solely to the testing situation. While stress or anxiety can influence blood pressure readings, it's essential to address the need for further evaluation and not completely disregard the possibility of hypertension.

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Correct Answer is D

Explanation

A. Lie in a low Fowler’s or supine position:

Lying in a low Fowler's or supine position may worsen respiratory distress and compromise oxygenation. It can reduce lung expansion and increase the work of breathing, especially in patients with pneumonia. This is not a recommended position for individuals with respiratory issues.

B. Increase oral fluids unless contraindicated:

Increasing oral fluids is generally a good practice, especially in respiratory conditions like pneumonia. It helps thin respiratory secretions, making them easier to clear. However, this alone may not address copious tracheobronchial secretions. Suctioning may be needed to effectively remove excess secretions.

C. Increase activity:

Increasing activity may be beneficial for some patients, but it might exacerbate respiratory distress in others, especially if they are already experiencing increased work of breathing. The appropriateness of increasing activity depends on the specific condition and the patient's overall stability.

D. Call the nurse for oral suctioning as needed:

This is the most appropriate choice. If the client is experiencing increased work of breathing due to copious tracheobronchial secretions, calling the nurse for oral suctioning is an intervention aimed at maintaining a clear airway and alleviating respiratory distress. Regular suctioning may be necessary to assist the client in managing secretions effectively.

A. The patient pain reflects the target heart rate has been set too high and needs to be lowered to finish the test. B. The patient’s pain reflects pericarditis and the test should be stopped. C. The patient’s pain reflects ischemia to the myocardium and the test should be stopped. D. The patient’s pain reflects that supplemental oxygen is needed to finish the test.

Correct Answer is C

Explanation

A. The patient pain reflects the target heart rate has been set too high and needs to be lowered to finish the test.

This option suggests that the chest pain is related to the target heart rate being set too high. However, chest pain during an exercise stress test is more commonly associated with myocardial ischemia rather than an inappropriate target heart rate. Lowering the target heart rate may not address the underlying issue of ischemia.

B. The patient’s pain reflects pericarditis and the test should be stopped.

Chest pain during an exercise stress test is more commonly associated with myocardial ischemia rather than pericarditis. Pericarditis is inflammation of the pericardium, and its symptoms may include chest pain that is often sharp and pleuritic. However, during an exercise stress test, the focus is on detecting cardiovascular abnormalities, and chest pain is more concerning for ischemia.

C. The patient’s pain reflects ischemia to the myocardium and the test should be stopped.

This is the most appropriate interpretation. Chest pain during an exercise stress test may indicate insufficient oxygen supply to the myocardium (ischemia). Stopping the test allows for further evaluation and appropriate intervention.

D. The patient’s pain reflects that supplemental oxygen is needed to finish the test.

Chest pain during an exercise stress test is not typically addressed by providing supplemental oxygen. Stopping the test and evaluating the cause of the chest pain is a more appropriate action.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A critical-care nurse is caring for a client diagnosed with pneumonia as a surgical complication. The nurse’s assessment reveals that the client has an increased work of breathing due to copious tracheobronchial secretions. What should the nurse encourage the patient to do?

Correct Answer is D

Explanation

The nurse is caring for a client who is undergoing an exercise stress test. Prior to reaching the target heart rate, the client develops chest pain. What is the nurse’s most appropriate interpretation of the chest pain?

Correct Answer is C

Explanation

The nurse is caring for a patient who has decreased mobility. Which intervention is a simple and cost-effective method for reducing the risks of stasis of pulmonary secretions and decreased chest wall expansion?

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What is the best indication if the client with congestive heart failure is holding excess fluid?

A client with a complex cardiac history is scheduled for transesophageal echocardiography. Which of the following statements, if made by the nurse, is inappropriate?

A client has chest pain rated 8/10 as stated by the patient. The 12-lead ECG reveals ST elevation in the inferior leads and the lab results reveal cardiac enzyme levels are elevated. What is the highest priority for nursing management of this client at this time?

The nurse is planning the care of a client with heart failure. The nurse should identify what overall goals for the client’s care? (SELECT ALL THAT APPLY)