A patient's blood pressure suddenly drops from 132/82 to 104/52. The nurse notes that the patient's skin is pale and the patient appears ready to faint. What is the priority action of the nurse?
Check the patient's apical rate to check for a pulse deficit.
Immediately check the client's carotid pulse.
Elevate the head of the patient's bed to at least 45 degrees.
Report the findings to the health care provider immediately.
The Correct Answer is B
A. Check the patient's apical rate to check for a pulse deficit. While an apical pulse assessment may be useful later, the priority in a sudden drop in blood pressure with signs of fainting is to ensure adequate circulation by checking a central pulse.
B. Immediately check the client's carotid pulse. A significant blood pressure drop (132/82 to 104/52), pale skin, and signs of fainting suggest possible shock or circulatory collapse. The carotid pulse should be checked immediately to assess perfusion.
C. Elevate the head of the patient's bed to at least 45 degrees. Raising the head of the bed could worsen hypotension and decrease blood flow to the brain, increasing the risk of syncope. The Trendelenburg position or lying flat may be more appropriate.
D. Report the findings to the health care provider immediately. While the provider should be notified, the priority action is to assess circulation by checking the carotid pulse first before escalating care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["50.9"]
Explanation
Calculation:
To convert pounds to kilograms, use the formula:
Kg = lb/2.2
Substituting the given value:
Kg = 112.2/2.2
= 50.9kg
Thus, 112.2 lb = 50.9 kg.
Correct Answer is D
Explanation
A. 40-year-old with a pulse of 88. A resting pulse of 88 beats per minute is within the normal adult range (60–100 bpm) and does not require further assessment.
B. 18-year-old with a pulse rate of 140 after riding 2 miles on an exercise bike. An increased heart rate after exercise is a normal physiological response, and the heart rate should return to baseline after rest. No further assessment is needed unless tachycardia persists.
C. 50-year-old man with a BP of 112/60 mmHg on awakening in the morning. This blood pressure is within a normal range, especially in the early morning when BP is often lower. No additional assessment is required.
D. 65-year-old with a respiratory rate of 10/min. A normal respiratory rate for an adult is 12–20 breaths per minute. A respiratory rate of 10 is lower than normal and may indicate respiratory depression, which could be caused by medications such as opioids, neurological issues, or other conditions requiring further evaluation.
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