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 A
Explanation
Choice A reason: This statement is correct, as adjuvant medications are drugs that are not primarily intended for pain relief, but can enhance the analgesic effect of other pain medications. Examples of adjuvant medications are antidepressants, anticonvulsants, or corticosteroids.
Choice B reason: This statement is false, as adjuvant medications can have significant side effects, depending on the type and dose of the drug. Some common side effects are drowsiness, nausea, dry mouth, or weight gain.
Choice C reason: This statement is misleading, as adjuvant medications are not used instead of opioids, but rather as an adjunct to opioids or other analgesics. Adjuvant medications can help reduce the dose of opioids needed to achieve pain relief, but they do not replace them entirely.
Choice D reason: This statement is inaccurate, as adjuvant medications are not used to eliminate the side effects of opioid medications, but rather to treat the underlying cause or mechanism of pain. Adjuvant medications can target different types of pain, such as neuropathic, inflammatory, or visceral pain.
Correct Answer is D
Explanation
Choice A reason: Overhydration is not the definition of the promotion of an adequate fluid balance, but rather a condition where the body has excess fluid volume, which can cause medical complications, such as edema, hyponatremia, or heart failure.
Choice B reason: Dehydration is not the definition of the promotion of an adequate fluid balance, but rather a condition where the body has insufficient fluid volume, which can cause medical complications, such as hypotension, tachycardia, or kidney failure.
Choice C reason: Hypernatremia is not the definition of the promotion of an adequate fluid balance, but rather a condition where the body has excess sodium concentration in the blood, which can cause medical complications, such as thirst, confusion, or seizures.
Choice D reason: Hydration is the definition of the promotion of an adequate fluid balance, as it refers to the maintenance of the optimal amount and distribution of fluid in the body, which can prevent medical complications, such as dehydration, electrolyte imbalance, or infection.
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