A nurse receives a report from an assistive personnel that a client's blood pressure is 160/95 mm Hg. Which of the following actions should the nurse take first?
Report the finding to the provider.
Compare the finding to the client's blood pressure baseline.
Administer antihypertensive medications as prescribed.
Recheck the client's blood pressure.
The Correct Answer is D
A. Report the finding to the provider. While the provider should be informed if the hypertension is new, persistent, or symptomatic, the nurse should first verify the blood pressure before escalating the concern.
B. Compare the finding to the client's blood pressure baseline. Checking the baseline is important, but the first action should be to confirm the accuracy of the reading by rechecking it. If the reading is consistent with previous values, the nurse can then compare it to the baseline.
C. Administer antihypertensive medications as prescribed. Administering medication without confirming the blood pressure reading could lead to unnecessary treatment or hypotension if the reading was inaccurate. The nurse should first recheck the BP.
D. Recheck the client's blood pressure. Rechecking the blood pressure ensures accuracy before making clinical decisions. Factors such as incorrect cuff size, client positioning, or transient increases (e.g., anxiety or pain) could cause an elevated reading. If the elevated BP is confirmed, then further action (e.g., notifying the provider or administering medication) can be taken.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Decreased blood urea nitrogen (BUN): BUN typically increases with dehydration.
B. Increased hematocrit: Hemoconcentration occurs in dehydration, increasing hematocrit levels.
C. Decreased urine specific gravity: Dehydration typically causes an increase in urine specific gravity.
D. Increased calcium level: Calcium levels do not directly indicate fluid volume status.
Correct Answer is B
Explanation
A. "I need to have an attorney sign my advance directives." An attorney is not required to sign an advance directive. The document typically requires the client’s signature and witnesses but does not need legal counsel unless state laws specify otherwise.
B. "I have a living will that outlines my wishes if I am unable to make decisions." A living will is a type of advance directive that specifies the client’s preferences for medical care if they become unable to make decisions. This statement shows understanding.
C. "I must have a family member appointed to make my health care decisions." While a client can appoint a family member as a healthcare proxy, it is not required. The client may choose any trusted individual to act as their healthcare power of attorney.
D. "I will need to sign a document stating that I want to be resuscitated if I require CPR." A Do Not Resuscitate (DNR) order is signed when a client chooses not to receive CPR. If the client wants resuscitation, no additional documentation is required—healthcare providers automatically provide life-saving measures unless a DNR order is in place.
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