A nurse on a medical-surgical unit is collecting data from a client who is postoperative following abdominal surgery.
The client’s BP was 126/72 mm Hg 15 min ago. The nurse now finds that the client’s BP is 176/96 mm Hg. Which of the following actions should the nurse take?
Deflate the cuff faster when repeating the BP measurement.
Request a prescription for an antihypertensive medication.
Use a narrower cuff to repeat the BP measurement.
Measure the client’s BP in the other arm.
The Correct Answer is D
It's common practice to check blood pressure in both arms when there is a significant discrepancy in blood pressure readings between the arms. This discrepancy could be due to factors like arterial blockages or other conditions. By measuring the blood pressure in the other arm, the nurse can confirm whether the high blood pressure is consistent on both sides or if there was an issue with the initial measurement. This step helps provide a more accurate assessment of the client's blood pressure.
- The other options are not appropriate at this stage:
Deflating the cuff faster may not resolve the issue and could lead to inaccurate measurements.
Requesting a prescription for an antihypertensive medication should only be done after confirming the blood pressure is consistently elevated and under the direction of a healthcare provider.
Using a narrower cuff is not indicated in this situation. It's more important to assess the other arm's blood pressure to identify any discrepancies.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Correct Answer is ["7"]
Explanation
Determine the total daily dose required in milligrams:
The prescribed dose is 80 mg/kg/day.
The child's weight is 35 kg.
Totaldailydose=80mg/kg/day×35kg
Calculate the total daily dose:
Totaldailydose=2800mg/day
Divide the total daily dose into four doses:
Doseperadministration: 2800mg/day ÷ 4 =700mg
Determine the volume of the oral suspension to administer per dose:
The available concentration of sucralfate oral suspension is 1 g/10 mL.
Convert 1 g to mg:
1g=1000mg.
Calculate the volume needed for 700 mg:
Volume(mL) = Desireddose(mg)÷Concentration(mg/mL)
Concentration = 1000mg÷10mL = 100mg/mL
Volume(mL) = 700 mg ÷ 100mg/mL
= 7 mL
Therefore, the nurse should administer 7 mL of sucralfate oral suspension per dose.
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