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.

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Correct Answer is B

Explanation

A. Dysrhythmia. Dysrhythmia refers to an irregular heart rhythm, not necessarily a fast heart rate. Tachycardia can be regular or irregular.
B. Tachycardia. Tachycardia is defined as a heart rate above 100 beats per minute in adults. A pulse rate of 110 to 140 bpm falls within this range.
C. Bradycardia. Bradycardia refers to a slow heart rate (below 60 bpm), which is the opposite of tachycardia.
D. Pyrexia. Pyrexia refers to fever (elevated body temperature), not an increased heart rate.

A. In the morning B. During periods of stress C. After exercising D. In the preoperative period

Correct Answer is A

Explanation

A. Body temperature follows a circadian rhythm, typically being lowest in the early morning (around 4–6 AM) and peaking in the late afternoon or evening.
B. Stress activates the sympathetic nervous system, which increases metabolic activity and raises body temperature rather than lowering it.
C. Physical activity generates heat, leading to an increase in body temperature, not a decrease.
D. While some surgical preparations involve cooling the patient, body temperature is not naturally lower before surgery. Instead, preoperative anxiety may even cause a slight increase in temperature.

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