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 B
Explanation
This type of aphasia is caused by damage to the frontal lobe of the brain, which affects the ability to produce language.
People with expressive aphasia can understand speech and know what they want to say, but they have difficulty saying words or forming sentences.
They may speak in short phrases that require a lot of effort.
Choice A is wrong because receptive aphasia is a type of fluent aphasia that affects the ability to comprehend language.
People with receptive aphasia have difficulty understanding speech and may produce meaningless words or sentences.
Choice C is wrong because global aphasia is the most severe type of aphasia that affects both the production and comprehension of language.
People with global aphasia cannot speak many words and do not understand speech.
They also cannot read or write.
Choice D is wrong because sensory aphasia is not a common term for a type of aphasia.
It may refer to Wernicke’s aphasia, which is another type of fluent aphasia that affects the ability to produce meaningful language.
People with Wernicke’s aphasia can speak fluently but often use incorrect or invented words or phrases.
Correct Answer is A
Explanation
Aspiration is when food or liquid enters the airway and causes choking or infection. Speech therapists can teach clients exercises to strengthen the muscles involved in swallowing, as well as strategies to prevent aspiration, such as changing the position of the head or the texture of the food.
Choice B is wrong because respiratory therapists help clients with breathing problems, not swallowing problems.
They may provide oxygen therapy, chest physiotherapy, or mechanical ventilation.
Choice C is wrong because physical therapists help clients with mobility problems, not swallowing problems.
They may provide exercises, massage, or assistive devices to improve movement and function.
Choice D is wrong because occupational therapists help clients with daily living activities, not swallowing problems.
They may provide training, adaptive equipment, or environmental modifications to enhance independence and quality of life.
Dysphagia is a medical term for swallowing difficulties.
It can be caused by various conditions that affect the nerves or muscles involved in swallowing, such as stroke, head injury, Parkinson’s disease, or esophageal cancer.
Dysphagia can lead to complications such as malnutrition, dehydration, or aspiration pneumonia.
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