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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Carotid. The carotid arteries supply blood to the brain, and compressing both simultaneously can reduce cerebral blood flow, potentially causing dizziness, syncope, or loss of consciousness. Therefore, carotid pulses should be assessed one at a time.
B. Radial. The radial pulse can be safely assessed bilaterally at the same time since it does not affect central circulation or brain perfusion.
C. Brachial. The brachial pulse can also be assessed bilaterally without risk, as it does not impact blood flow to critical organs like the brain.
D. Femoral. The femoral pulse can be checked simultaneously on both sides to assess circulation and perfusion, especially in cases of suspected arterial insufficiency.

A. apical B. radial C. brachial D. popliteal

Correct Answer is A

Explanation

A. Apical. The apical pulse, located at the apex of the heart, provides the most accurate measurement of heart rate, especially in patients with irregular rhythms. It is assessed by auscultation with a stethoscope over the fifth intercostal space at the midclavicular line.
B. Radial. The radial pulse is commonly used for routine pulse checks, but it may be less accurate in cases of irregular heart rhythms or weak peripheral circulation.
C. Brachial. The brachial pulse is typically used in infants and for blood pressure measurements, but it is not the most accurate method for assessing heart rate.
D. Popliteal. The popliteal pulse is located behind the knee and is used to assess circulation to the lower extremities, not for measuring heart rate accurately.

View Question and Answer

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

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a patient's bilateral pulses for symmetry. Which pulse site should not be assessed on both sides of the body at the same time?

Correct Answer is A

Explanation

Which method will provide the most accurate measurement of the patient's heart rate?

Correct Answer is A

Explanation

Which instruction will the nurse give to the patient about proper use of patient-controlled analgesia (PCA)?

When evaluating the client's temperature levels, the nurse expects the client's temperature to be lower:

Which technique will provide the most accurate measurement of the patient's core temperature?

A patient has a morphine sulfate patient-controlled analgesia (PCA) to control postoperative pain. When the nurse enters the room, the patient complains of pain. The nurse's first response is which of the following?

The nurse is observing the auscultation technique of a student nurse. What is the correct method to use when progressing from one auscultatory site on the thorax to another?

After noting that a client has a pulse deficit, what action should the nurse take next?

A nurse is preparing to administer an opioid agonist to a client who has acute pain. For which of the following manifestations should the nurse monitor as an adverse effect of this medication?

Exhibits Lana is developing Mrs. Watson's care plan. She wants to add more interventions and not just deliver pain medication. What are some other nursing actions that would be helpful to Mrs. Watson? Select the 4 correct answers (Case Study #2)