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 an antihypertensive medication as prescribed.
Recheck the client’s blood pressure.
The Correct Answer is D
Choice A rationale
Reporting elevated blood pressure is important; however, verifying the accuracy of the reading ensures reliable data before initiating any interventions or contacting the provider.
Choice B rationale
While baseline comparison is essential, rechecking ensures accuracy and rules out any transient factors or equipment errors causing the abnormal blood pressure reading.
Choice C rationale
Administering antihypertensives without confirming the abnormal reading may lead to potential hypotension or overtreatment if the initial measurement was inaccurate.
Choice D rationale
Rechecking the blood pressure confirms accuracy, rules out transient elevations or equipment issues, and provides reliable data for appropriate clinical decision-making and subsequent actions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Applying clean dressings over blood-saturated ones helps maintain sterility and pressure, minimizing further bleeding while reducing the risk of contamination or infection.
Choice B rationale
Hydrogen peroxide can delay healing by causing tissue damage through cytotoxic effects on fibroblasts and keratinocytes.
Choice C rationale
Removing objects from penetrating wounds can worsen internal injuries or cause hemorrhage, as the object may be tamponading bleeding vessels.
Choice D rationale
Placing the affected area in a dependent position increases venous pressure, exacerbating swelling and potentially worsening bleeding or tissue damage.
Correct Answer is B
Explanation
Choice A rationale
Exercising close to bedtime increases adrenaline and body temperature, which interfere with sleep initiation. Studies recommend ceasing vigorous activity at least 3-4 hours before bedtime to optimize sleep quality.
Choice B rationale
Reducing fluid intake before bed minimizes nocturia, a common sleep disturbance. This aligns with promoting uninterrupted sleep and improving overall sleep hygiene and quality for individuals with insomnia.
Choice C rationale
Taking daytime naps, especially longer than 30 minutes, disrupts circadian rhythms and sleep drive, contributing to difficulty initiating and maintaining sleep during regular hours.
Choice D rationale
Eating a large meal before bedtime delays gastric emptying and may cause discomfort or reflux, both of which interfere with falling asleep. Light snacks are recommended if needed, but not heavy meals.
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