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","B","C","E"]
Explanation
Choice A reason: Heart failure can cause fluid retention, which can lead to dehydration if the fluid is not properly balanced.
Choice B reason: Functional impairments can limit the ability to drink or access fluids, which can increase the risk of dehydration.
Choice C reason: Longitudinal furrows on the tongue are a sign of dehydration, as the tongue loses moisture and becomes dry and cracked.
Choice D reason: Hypertension is not directly related to dehydration, although it can be affected by fluid intake and electrolyte balance.
Choice E reason: Diabetes can cause increased urination, which can lead to dehydration if the fluid loss is not replaced.
Correct Answer is ["A","B","D","E"]
Explanation
Choice A: Pressure ulcers - Physical restraints can lead to immobility, which increases the risk of pressure ulcers due to prolonged pressure on the skin.
Choice B: Death - Restraints can cause fatal accidents. For example, a person might try to remove the restraint, fall, and suffer a fatal injury.
Choice C: Sepsis - While sepsis is a severe condition often caused by an infection, it's not a direct result of physical restraints. However, if a pressure ulcer (caused by restraints) becomes severely infected, it could potentially lead to sepsis.
Choice D: Decreased circulation/perfusion to the extremities - Restraints can restrict movement, leading to decreased blood flow to the extremities.
Choice E: Fractures - Struggling against restraints can lead to falls and subsequent fractures.
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