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 B
Explanation
A. Positioning the bell very lightly over the patient's sternum. The bell is best for low-pitched sounds like murmurs, but heartbeats (especially S1 and S2) are better heard with the diaphragm over the apex of the heart, not the sternum.
B. Placing the diaphragm firmly against the patient's skin. The diaphragm is designed to pick up high-pitched sounds like the normal S1 and S2 heart sounds. Pressing firmly helps eliminate external noise and improves sound clarity.
C. Utilizing a stethoscope with the longest possible tubing. Longer tubing can reduce sound transmission quality. Shorter tubing (about 14-18 inches) provides clearer sound.
D. Making sure that the earpieces fit loosely in the nurse's ear canals. Earpieces should fit snugly, not loosely, to ensure optimal sound conduction and block external noise.
Correct Answer is B
Explanation
A. Perception. Perception occurs when the brain processes and interprets the pain signal, which happens after the stimulus has been converted and transmitted.
B. Transduction. Transduction is the process where a painful stimulus, such as touching a hot stove, causes cellular damage, leading to the release of chemical mediators that convert the stimulus into a pain impulse.
C. Modulation. Modulation involves the body's response to pain, including the release of endorphins to inhibit pain signals and reduce pain sensation.
D. Transmission. Transmission refers to the movement of the pain impulse from the site of injury to the spinal cord and brain, occurring after transduction has taken place.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.