A nurse measures an older adult's blood pressure on the right arm and notes a reading of 150/100. The nurse waits 5 minutes and measures the blood pressure again in the right arm and obtains a reading of 152/100. What is the next action by the nurse?
Measure the blood pressure in sitting and standing positions.
Measure the blood pressure in the left arm.
Document the findings in the medical record; elevated blood pressures are normal in older adults.
Immediately contact the medical provider.
None of the above.
The Correct Answer is B
Choice A reason: Measure the blood pressure in sitting and standing positions is not the next action by the nurse, as it is not relevant to the situation. The nurse should compare the blood pressure readings from both arms, not from different postures.
Choice B reason: Measure the blood pressure in the left arm is the next action by the nurse, as it can help determine if the high blood pressure is consistent or isolated to one arm. A difference of more than 10 mm Hg between the arms may indicate a vascular problem, such as atherosclerosis, aneurysm, or coarctation of the aorta.
Choice C reason: Document the findings in the medical record; elevated blood pressures are normal in older adults is not the next action by the nurse, as it is inaccurate and irresponsible. The nurse should not assume that elevated blood pressures are normal in older adults, as they may indicate hypertension, which is a risk factor for cardiovascular disease, stroke, and kidney damage. The nurse should also not document the findings without further assessment and intervention.
Choice D reason: Immediately contact the medical provider is not the next action by the nurse, as it may be premature and unnecessary. The nurse should first confirm the accuracy of the blood pressure readings by measuring the blood pressure in the left arm and checking the calibration of the device. The nurse should also consider other factors that may affect the blood pressure, such as pain, stress, caffeine, or medication.
Choice E reason: None of the above is not the correct answer, as there is one choice that is the next action by the nurse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
Choice A: Use an antifungal cleanser daily. This is not a correct answer. Antifungal cleansers are not recommended for treating fungal infections, as they can irritate the skin and disrupt the natural balance of the skin flora¹. Antifungal cleansers may also reduce the effectiveness of other antifungal medications².
Choice B: Eliminate the conditions that created the problem. This is a correct answer. Fungal infections are often caused by factors that create a favorable environment for fungi to grow, such as moisture, warmth, poor hygiene, or weakened immunity³. Eliminating these conditions can help prevent or treat fungal infections by reducing the fungal load and restoring the skin barrier.
Choice C: Thoroughly clean and dry skin daily. This is also a correct answer. Cleaning and drying the skin daily can help remove dirt, sweat, and dead skin cells that can harbor fungi and cause infections. Drying the skin well, especially in the folds and creases, can also prevent moisture buildup that can promote fungal growth.
Choice D: Apply 4x4 dressings to the affected site.This is not a correct answer. Applying dressings to the affected site can trap moisture and heat, which can worsen fungal infections. Dressings may also interfere with the absorption of topical antifungal medications. Dressings are only indicated for fungal infections that cause open wounds or ulcers, and they should be changed frequently and kept clean and dry..
Correct Answer is B
Explanation
Choice A reason: Over-the-counter NSAIDs are generally harmless is not a true statement, as NSAIDs can cause serious adverse effects in older adults, such as gastrointestinal bleeding, renal impairment, hypertension, and heart failure. NSAIDs should be used with caution and under medical supervision in older adults.
Choice B reason: Stool softeners and laxatives should be used with opioids is a true statement, as opioids can cause constipation in older adults, which can lead to discomfort, abdominal pain, fecal impaction, and bowel obstruction. Stool softeners and laxatives can help prevent and treat constipation and promote regular bowel movements.
Choice C reason: Opioids are less effective in older clients than in younger clients is not a true statement, as opioids can have the same or even greater analgesic effect in older adults, depending on the dose, route, and duration of administration. However, opioids can also cause more side effects in older adults, such as sedation, confusion, respiratory depression, and falls. Opioids should be used with caution and under medical supervision in older adults.
Choice D reason: The dose limit for acetaminophen is difficult to reach for older adults is not a true statement, as older adults may be more susceptible to acetaminophen toxicity, especially if they have liver disease, malnutrition, or chronic alcohol use. The dose limit for acetaminophen is 4 grams per day for adults, but it may be lower for older adults or those with risk factors. Acetaminophen should be used with caution and under medical supervision in older adults.
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