A patient with a history of hypertension arrives in the emergency department with a blood pressure (BP) reading of 213/126 mm Hg. The patient has a history of drug abuse.

Which of the following initial questions posed by the nurse is MOST appropriate?.

"Did you take any Tylenol today?".

"Have there been recent stressful events in your life?".

"Have you recently taken any cocaine or crack?".

"Have you eaten any salty foods lately?". .

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Tylenol, or acetaminophen, is a common over-the-counter medication used to reduce fevers and manage mild aches and pains. It does not directly affect blood pressure.

Choice B rationale:

While stress can cause temporary spikes in blood pressure, it’s not clear whether stress can cause long-term increases in blood pressure34.

Choice C rationale:

Cocaine or crack use can cause a significant and dangerous increase in blood pressure. Given the patient’s history of drug abuse and the current high blood pressure reading, this is a critical question to ask.

Choice D rationale:

Eating salty foods can contribute to high blood pressure over time, but it’s unlikely to cause an immediate severe increase in blood pressure.

So, the correct answer is Choice C, after analyzing all choices. .

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Correct Answer is ["C","E","G","H"]

Explanation

Choice A rationale:

The apical pulse rate increased from 90/min to 112/min, which is still within the normal range (60-100 beats per minute). Therefore, it’s not a critical change.

Choice B rationale:

The adolescent’s position, supine with legs straight, is the recommended position after cardiac catheterization to prevent bleeding from the femoral artery puncture site.

Choice C rationale:

The pulses of the right extremity decreased to 2+, indicating reduced blood flow. This is a critical finding and should be reported.

Choice D rationale:

The pain increased from 0 to 2 on a scale of 0 to 10. While any increase in pain should be monitored, a score of 2 is not typically considered severe.

Choice E rationale:

The pressure dressing became saturated with bloody drainage, indicating possible bleeding. This is a critical finding and should be reported.

Choice F rationale:

The respiratory rate increased from 16/min to 18/min, which is still within the normal range (12-20 breaths per minute). Therefore, it’s not a critical change.

Choice G rationale:

The blood pressure decreased from 120/76 mm Hg to 100/52 mm Hg. A significant drop in blood pressure can indicate blood loss or shock. This is a critical finding and should be reported.

Choice H rationale:

The right lower extremity became cool and pale, indicating reduced blood flow. This is a critical finding and should be reported.

So, the correct answer is Choice C, E, G, H, after analyzing all choices. .

A. Temperature. B. Oxygen saturation. C. Blood pressure. D. Weight. E. Urine output. F. Breath sounds.

Correct Answer is ["B","C","D","F"]

Explanation

Choice A rationale:

The client’s temperature decreased from 37.6°C to 36.8°C1. This is within the normal body temperature range of 36.5°C to 37.2°C2, so it does not require further action.

Choice B rationale:

The client’s oxygen saturation decreased from 95% to 88%1. Normal pulse oximetry values are typically above 95%2. This decrease could indicate that the client is not getting enough oxygen, which requires further action.

Choice C rationale:

The client’s blood pressure increased from 108/50 mm Hg to 138/80 mm Hg. Normal blood pressure for adults is below 120/80 mm Hg. This increase could indicate worsening heart failure, which requires further action.

Choice D rationale:

The client’s weight increased from 80 kg to 82.1 kg. Rapid weight gain may be a sign of fluid retention, a common symptom of heart failure. This requires further action.

Choice E rationale:

The client’s urine output decreased from 480 mL/8 hr to 320 mL/8 hr.However it is still above 30ml/hr signifying normal renal function

Choice F rationale:

On Day 4, the client’s breath sounds were scattered, and crackles were heard bilaterally. This could indicate fluid accumulation in the lungs, a common symptom of heart failure. This requires further action.

So, the correct answer is Choices B, C, D, and F, after analyzing all choices.

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A patient with a history of hypertension arrives in the emergency department with a blood pressure (BP) reading of 213/126 mm Hg. The patient has a history of drug abuse. Which of the following initial questions posed by the nurse is MOST appropriate?.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for an adolescent following a cardiac catheterization. Exhibits Which of the following assessment findings should the nurse report to the provider? Select the 4 findings that the nurse should report to the provider.

Correct Answer is ["C","E","G","H"]

Explanation

Correct Answer is ["B","C","D","F"]

Explanation

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A patient with a history of hypertension arrives in the emergency department with a blood pressure (BP) reading of 213/126 mm Hg. The patient has a history of drug abuse.

Which of the following initial questions posed by the nurse is MOST appropriate?.