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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: Administering potassium supplements may be appropriate, but the nurse must first notify the provider to confirm the treatment plan. Unilateral administration without provider input could lead to incorrect dosing.
Choice B rationale: Notifying the provider of the laboratory results is the priority to ensure prompt medical evaluation and intervention. The provider will determine the appropriate course of action based on the client's clinical condition and lab results.
Choice C rationale: Encouraging the client to eat potassium-rich foods is not the initial action. Diet changes take time to affect potassium levels, and immediate intervention is required to address the hypokalemia.
Choice D rationale: Monitoring for signs of hyperkalemia is inappropriate since the client has low potassium levels. The priority is to manage hypokalemia and prevent further complications.
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
Observations about family relationships may provide context, but they are subjective and irrelevant to a transfer report, which prioritizes clinical and objective data for continuity of care.
Choice B rationale
Response to pain medication offers insight into the client's current pain management efficacy, helping the receiving team adjust care interventions to meet ongoing needs effectively and efficiently.
Choice C rationale
A review of the ongoing discharge plan ensures coordinated care, highlighting the next steps or unresolved issues to facilitate smooth transition and continuity between care teams or settings.
Choice D rationale
Recent physical changes are crucial as they inform care providers of the client’s evolving condition, enabling timely and appropriate medical or nursing interventions upon admission to the new unit.
Choice E rationale
Comprehensive demographic information is already documented in client records and does not provide immediate clinical relevance for transfer reports, which focus on dynamic health and treatment concerns.
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