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 C
Explanation
A. Limit the use of hand gestures when communicating with the client. Hand gestures enhance communication for clients with hearing loss. Visual cues such as gestures, facial expressions, and lip reading can help improve understanding.
B. Speak to the client with an increased pitch. Speaking in an increased pitch is not recommended because higher frequencies are often harder for clients with hearing loss to detect. Instead, the nurse should speak clearly, slowly, and in a lower tone.
C. Use written materials to assist with communication. Written materials help clients with hearing loss understand important information, especially if they rely on lip reading or have significant hearing impairment.
D. Limit visitors to avoid communication misunderstandings. Limiting visitors is unnecessary and may lead to social isolation. Instead, the nurse should encourage communication using appropriate strategies, such as writing or sign language.
Correct Answer is B
Explanation
A. "Hold your breath for 6 seconds after inhaling the medication." – The correct recommendation is to hold the breath for at least 10 seconds to allow maximum medication absorption in the lungs.
B. "Inhale the medication deeply for 5 seconds." – A slow, deep inhalation (3-5 seconds) allows the medication to reach the lower airways effectively.
C. "Do not shake the medication in the inhaler." – Most metered-dose inhalers (MDIs) need to be shaken before use to ensure proper mixing of medication. Exceptions include dry powder inhalers (DPIs), which should not be shaken.
D. "Hold the inhaler 3 inches away from your mouth." – The correct distance is 1 to 2 inches (2-4 cm) from the mouth, or the mouthpiece can be placed directly into the mouth with lips sealed around it.
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