A nurse is assessing a client's blood pressure and finds a significant difference between the blood pressure readings in the client's right and left arms. What action should the nurse take?
Recheck the blood pressure using a different cuff size.
Document the blood pressure findings as the only action required.
Notify the healthcare provider of the significant difference.
Perform a Doppler ultrasound to assess blood flow.
The Correct Answer is C
Answer: c. Notify the healthcare provider of the significant difference.
Explanation: A significant difference in blood pressure readings between the right and left arms may indicate arterial occlusion or other circulatory abnormalities. The nurse should notify the healthcare provider for further evaluation and intervention.
a. Rechecking the blood pressure with a different cuff size may be appropriate if the initial readings were inaccurate, but it does not address the significant difference between the arms.
b. Documenting the finding is important, but further action is required to investigate the cause of the discrepancy.
d. Performing a Doppler ultrasound may be done as part of the diagnostic process to assess blood flow, but the healthcare provider should be notified first for appropriate evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Explanation: A respiratory rate of 8 breaths per minute is significantly below the normal range (12-20 breaths per minute), indicating potential respiratory distress. The nurse should perform a thorough respiratory assessment to gather more information and determine appropriate interventions.
a. Administering oxygen may be necessary, but the nurse should first assess the client's respiratory status before initiating any interventions.
b. Placing the client in a supine position is not indicated and may worsen respiratory distress in some situations.
c. Reassessing after 1 hour is not appropriate when a client is experiencing abnormal vital signs; immediate action is needed.
Correct Answer is D
Explanation
Answer: d. Notify the healthcare provider of the elevated blood pressure.
Explanation: A blood pressure reading of 160/100 mmHg indicates hypertension and requires further evaluation by the healthcare provider to determine appropriate management.
a. Rechecking the blood pressure with a different cuff size may be appropriate if the initial reading was inaccurate, but it does not address the elevated blood pressure result.
b. Documenting the finding is important, but further action is required for elevated blood pressure.
c. Administering antihypertensive medication without consulting the provider is not appropriate; medication decisions should be made by the healthcare provider.
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