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 B
Explanation
Choice A rationale
Decreased blood urea nitrogen (BUN) reflects impaired protein catabolism or renal dysfunction rather than fluid volume status. Normal BUN ranges are 6-20 mg/dL, and deficit elevates this value.
Choice B rationale
Increased hematocrit suggests hemoconcentration due to reduced plasma volume, characteristic of fluid deficit. Normal hematocrit levels range from 38%-46% in women and 40%-54% in men.
Choice C rationale
Decreased urine specific gravity, below 1.005, indicates dilute urine, typically seen in fluid overload rather than deficit. Fluid deficit presents with a value above 1.030, indicating concentrated urine.
Choice D rationale
Increased calcium level, above 10.5 mg/dL, relates to hypercalcemia rather than fluid deficit. It is unrelated to intravascular volume status and may arise from other conditions like hyperparathyroidism.
Correct Answer is B
Explanation
Choice A rationale
At 15 months, toddlers typically lack the motor coordination required for precise balance needed to walk on tiptoes. This skill usually develops closer to 2-3 years of age.
Choice B rationale
Walking without assistance using a wide stance reflects a 15-month-old's gross motor development, as toddlers at this age begin independent walking with a broad base to enhance stability.
Choice C rationale
An accentuated cervical curvature when standing is not a normal feature of gross motor development at 15 months. Such a curvature is more associated with postural abnormalities or older age.
Choice D rationale
Standing with feet turned slightly inward is not typical at 15 months. Foot alignment is usually neutral; inward alignment could indicate conditions like intoeing, which requires evaluation.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.