A nurse is assessing a client's blood pressure and finds it to be 160/90 mmHg. What action should the nurse take?
Document the blood pressure as normal.
Recheck the blood pressure after 30 minutes.
Initiate antihypertensive medication.
Instruct the client to increase salt intake.
The Correct Answer is C
Answer: c. Initiate antihypertensive medication.
Explanation: A blood pressure reading of 160/90 mmHg indicates hypertension (high blood pressure). The nurse should initiate antihypertensive medication and implement other interventions as appropriate to manage and control blood pressure.
a. Documenting the blood pressure as normal would be inaccurate since it exceeds the normal range.
b. Rechecking the blood pressure after 30 minutes may delay appropriate intervention if the blood pressure remains elevated.
d. Instructing the client to increase salt intake is not appropriate for managing hypertension, as sodium intake can exacerbate high blood pressure.
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Related Questions
Correct Answer is C
Explanation
Answer: c. Initiate lifestyle modifications and monitor blood pressure.
Explanation: A blood pressure reading of 140/90 mmHg on multiple occasions indicates stage 1 hypertension. The nurse should initiate lifestyle modifications, such as diet changes, exercise, and stress reduction, and closely monitor the client's blood pressure. Antihypertensive medication may be considered if lifestyle modifications are not effective.
a. Documenting the blood pressure as normal would be inaccurate since it exceeds the normal range.
b. Rechecking the blood pressure after 1 week may delay appropriate intervention if the blood pressure remains elevated.
d. Administering anticoagulant medication is not indicated solely based on an elevated blood pressure reading.
Correct Answer is A
Explanation
Answer: a. Document the blood pressure as normal.
Explanation: A blood pressure reading of 90/60 mmHg is within the normal range for some individuals, especially those with low-normal blood pressure. The nurse should document the blood pressure as normal and consider the client's overall health and clinical condition.
b. Rechecking the blood pressure after 1 hour is not necessary unless there are specific concerns or symptoms indicating a need for further assessment.
c. Initiating intravenous fluid therapy is not indicated solely based on a blood pressure reading within the normal range.
d. Administering a vasopressor medication is not appropriate based solely on a blood pressure reading within the normal range.
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