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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Takes several steps on tiptoes. Typically develops around 24 months, not 15 months.

B. Walks without assistance using a wide stance. At 15 months, toddlers typically walk independently with a wide stance to improve balance.

C. Has an accentuated cervical curvature when standing. Not an expected motor milestone.

D. Stands with the feet turned slightly inward. Inward foot positioning can indicate a developmental delay or foot abnormality.

A. "I need to have an attorney sign my advance directives." B. "I have a living will that outlines my wishes if I am unable to make decisions." C. "I must have a family member appointed to make my health care decisions." D. "I will need to sign a document stating that I want to be resuscitated if I require CPR."

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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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?

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Naxlex Comprehensive Predictor Exams

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