A nurse in the ER is caring for a patient who had fallen at home. She reviews the blood pressure reading of 160/80 mm Hg. The client denies any history of hypertension. Which of the following actions should the nurse take first?
Ask the client if she is having pain
Request a prescription for an antianxiety medication
Request a prescription for an antihypertensive medication
Return in 30 min to recheck the client’s blood pressure
The Correct Answer is A
A. Ask the client if she is having pain.
This option recognizes the potential relationship between pain and elevated blood pressure. Assessing the client for pain is crucial, as pain can contribute to increased blood pressure.
B. Request a prescription for an antianxiety medication.
This option assumes that anxiety might be the cause of the elevated blood pressure. However, without further assessment, it may not be appropriate to jump to prescribing medication for anxiety.
C. Request a prescription for an antihypertensive medication.
Initiating antihypertensive medication without further assessment may not be the most appropriate first step, especially if the elevated blood pressure is related to pain or another temporary factor.
D. Return in 30 minutes to recheck the client’s blood pressure.
While monitoring blood pressure is important, waiting 30 minutes without further assessment or intervention might delay addressing the underlying issue, especially if it is related to pain or another acute problem.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["6"]
Explanation
To calculate the amount of ampicillin needed for one dose, we need to use a proportion. We can set up the proportion as follows:
150 mg / x mL = 125 mg / 5 mL
We can cross-multiply and solve for x:
150 * 5 = 125 * x
750 = 125 * x
x = 750 / 125
x = 6
Therefore, we need 6 mL of ampicillin for one dose
Correct Answer is ["B","D","E"]
Explanation
A. Wait 30 min and return to measure the oral temperature:
Waiting 30 minutes may not be necessary. It's more practical to take immediate steps to address potential factors affecting the reading.
B. Provide the client a sip of warm water, wait 5 min, and measure the temperature:
This can be a reasonable and practical approach to stimulate blood flow in the oral cavity and achieve a more accurate oral temperature reading.
C. Document that the nurse was unable to measure the client’s temperature:
Before documenting an inability to measure the temperature, the nurse should attempt appropriate interventions, such as warming the oral cavity or using an alternate route
D. Determine if the client has eaten or drank within the last 15 minutes:
Eating or drinking something cold shortly before taking an oral temperature can result in a lower reading. Checking for recent intake is important to ensure the accuracy of the measurement.
E. Use an alternate route (i.e., axillary, rectal) to take the client’s temperature:
If the oral temperature reading remains difficult to obtain or is not reliable, using an alternate route may be necessary. However, this depends on the client's condition, the reason for the temperature measurement, and the healthcare facility's protocols.
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