A medical assistant obtains an elevated blood pressure reading from a visibly upset patient. Which of the following actions should the assistant take?
Perform orthostatic blood pressure.
Recheck the blood pressure after a few minutes.
Measure blood pressure at the wrist.
Use the palpatory method for blood pressure.
The Correct Answer is B
A. Perform orthostatic blood pressure. Orthostatic blood pressure measurements are used to assess changes in blood pressure when a patient moves from lying down to standing, not in response to emotional upset.
B. Recheck the blood pressure after a few minutes. This is the correct action, as the initial elevated reading could be due to the patient's emotional state. Waiting a few minutes and rechecking can provide a more accurate reading.
C. Measure blood pressure at the wrist. Wrist blood pressure readings are less accurate than those taken at the upper arm and are not recommended in this scenario.
D. Use the palpatory method for blood pressure. The palpatory method is used when auscultation is difficult, but it does not address the issue of an elevated reading due to emotional upset.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Irrigate the wound with sterile normal saline. Irrigating the wound with sterile normal saline is the appropriate action for cleaning a contaminated wound, as it helps to remove debris and reduce the risk of infection.
B. Insert liquid bandage into the wound. A liquid bandage is not appropriate for a contaminated wound, especially if the wound is jagged, as it could trap contaminants inside.
C. Wash the wound with soap and warm water. While soap and water are good for general wound cleaning, sterile normal saline is preferred for contaminated wounds in a clinical setting to minimize irritation and infection.
D. Apply microporous tape to the wound. Microporous tape is used for securing dressings, not for cleaning wounds.
Correct Answer is B
Explanation
A. Wipe away the first five drops of blood after puncturing: Only the first drop of blood should be wiped away to remove any tissue fluid, not the first five drops.
B. Apply even pressure to the finger during the collection: Applying even pressure helps to promote blood flow without causing hemolysis or excessive squeezing, which could affect test results.
C. Puncture the index finger at the tip: The recommended site for a capillary puncture is the side of the middle or ring finger, not the tip of the index finger.
D. Puncture parallel to the fingerprint: The puncture should be made perpendicular to the fingerprint ridges to ensure an adequate blood flow and reduce the risk of blood running along the ridges.
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