A nurse is assessing a client's blood pressure and finds it to be 90/60 mmHg. What action should the nurse take?
Document the blood pressure as normal.
Recheck the blood pressure after 1 hour.
Initiate intravenous fluid therapy.
Administer a vasopressor medication.
The Correct Answer is A
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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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 D
Explanation
Answer: d. Measurement using a sphygmomanometer and stethoscope
Explanation: To accurately measure blood pressure, the nurse should use a sphygmomanometer and stethoscope. This allows for the auscultatory method of blood pressure measurement, which involves listening for Korotkoff sounds to determine systolic and diastolic blood pressure.
a. Palpation of the client's radial pulse provides information about the pulse rate but does not accurately measure blood pressure.
b. Auscultation of lung sounds assesses respiratory function but does not directly measure blood pressure.
c. Visual observation of skin color can provide information about circulation but does not provide an accurate measurement of blood pressure.
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