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?

Report the findings to the health care provider immediately.

Check the patient’s apical rate to check for a pulse deficit.

Immediately check the patient for orthostatic hypotension.

Elevate the head of the patient’s bed to at least 45 degrees.

Answer and Explanation

The Correct Answer is C

Choice A reason: This is incorrect. Reporting the findings to the health care provider immediately is an important step, but not the priority action of the nurse. The nurse should first assess the patient for orthostatic hypotension, which is a common cause of sudden blood pressure drop.

Choice B reason: This is incorrect. Checking the patient’s apical rate to check for a pulse deficit is a relevant step, but not the priority action of the nurse. A pulse deficit is the difference between the apical and radial pulse rates. The nurse should first check the patient for orthostatic hypotension, which is a condition where the blood pressure drops when the patient changes position, causing dizziness and fainting.

Choice C reason: This is correct. Immediately checking the patient for orthostatic hypotension is the priority action of the nurse. Orthostatic hypotension is a condition where the blood pressure drops when the patient changes position, causing dizziness and fainting. It can be caused by dehydration, medications, blood loss, or autonomic nervous system disorders. The nurse should measure the patient’s blood pressure and heart rate while lying down, sitting, and standing, and observe for any signs of hypoperfusion, such as pallor, sweating, or confusion.

Choice D reason: This is incorrect. Elevating the head of the patient’s bed to at least 45 degrees is a helpful step, but not the priority action of the nurse. Elevating the head of the bed can improve the patient’s breathing and reduce the risk of aspiration, but it can also worsen the orthostatic hypotension by lowering the blood pressure further. The nurse should first check the patient for orthostatic hypotension and then adjust the bed position accordingly.

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 C

Explanation

Choice A reason: This is an incorrect choice because the hospice RN works closely with the patient’s daughter to ensure that the patient’s dying requests are met is not a patient assignment that demonstrates the concept of team nursing. Team nursing is a model of care in which a team of healthcare providers, including RNs, licensed practical nurses (LPNs), nursing assistants, and other support staff, work together to provide care for a group of patients¹. Working closely with the patient’s daughter is an example of family-centered care, not team nursing.

Choice B reason: This is an incorrect choice because the RN cares for the same five patients every day during their stay following joint replacement surgery is not a patient assignment that demonstrates the concept of team nursing. Team nursing is a model of care in which a team of healthcare providers, including RNs, licensed practical nurses (LPNs), nursing assistants, and other support staff, work together to provide care for a group of patients¹. Caring for the same five patients every day is an example of primary nursing, not team nursing.

Choice C reason: This is the correct choice because the RN, the LPN, and the nursing assistant work together to provide all the care needed by eight patients for the shift is a patient assignment that demonstrates the concept of team nursing. Team nursing is a model of care in which a team of healthcare providers, including RNs, licensed practical nurses (LPNs), nursing assistants, and other support staff, work together to provide care for a group of patients¹. Each member of the team performs specific duties appropriate to their role to provide total patient care. Teams may include licensed practical nurses (LPNs) and unlicensed assistive personnel (UAP) that are supervised by a registered nurse (RN). Less experienced, or non-critical care RNs, may be assigned to a team in a critical care unit led by an experienced critical care RN. Each team member plays a vital role.

Choice D reason: This is an incorrect choice because the RN coordinates care of the patient with the physician assistant to ensure that the clinical pathway is followed is not a patient assignment that demonstrates the concept of team nursing. Team nursing is a model of care in which a team of healthcare providers, including RNs, licensed practical nurses (LPNs), nursing assistants, and other support staff, work together to provide care for a group of patients¹. Coordinating care of the patient with the physician assistant is an example of interprofessional collaboration, not team nursing.

A. The patient’s lung sounds are diminished bilaterally with expiratory wheezes. B. The patient worries that the insurance company will not pay the hospital bill. C. The patient wonders if supplemental oxygen at home would be beneficial. D. The patient felt less short of breath after receiving a nebulizer treatment.

Correct Answer is A

Explanation

Choice A reason: This is the correct choice because the patient’s lung sounds are diminished bilaterally with expiratory wheezes is an example of objective data. Objective data is observable and measurable information that can be verified by the nurse or other health care professionals. The nurse can use a stethoscope to listen to the patient’s lung sounds and document the findings.

Choice B reason: This is an incorrect choice because the patient worries that the insurance company will not pay the hospital bill is an example of subjective data. Subjective data is what the patient tells the nurse about their symptoms, feelings, perceptions, and concerns. The nurse cannot observe or measure the patient’s worry, but can only rely on the patient’s verbal report.

Choice C reason: This is an incorrect choice because the patient wonders if supplemental oxygen at home would be beneficial is an example of subjective data. Subjective data is what the patient tells the nurse about their symptoms, feelings, perceptions, and concerns. The nurse cannot observe or measure the patient’s wonder, but can only rely on the patient’s verbal report.

Choice D reason: This is an incorrect choice because the patient felt less short of breath after receiving a nebulizer treatment is an example of subjective data. Subjective data is what the patient tells the nurse about their symptoms, feelings, perceptions, and concerns. The nurse cannot observe or measure the patient’s feeling, but can only rely on the patient’s verbal report.

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

Which patient assignment demonstrates the concept of team nursing?

Correct Answer is C

Explanation

Which data will the nurse categorize as objective for a patient who has just completed an assessment?

Correct Answer is A

Explanation

The nurse is having difficulty hearing his patient’s apical pulse with his stethoscope. Which action will help the nurse hear the heartbeat more clearly?

Which assessment findings put the patient at high risk for development of vision problems? (Select all that apply)

Which intervention is most appropriate to treat ongoing insomnia for a middle-aged adult with a busy career?

To promote adequate sleep for a patient who suffers from a sleep pattern disturbance, what are the most appropriate nursing interventions? (Select all that apply).

The nurse is caring for a patient who is having a heart attack. The patient tells the nurse that the pain is down his left arm rather than in his chest. What type of pain is the patient experiencing?

Which site will the nurse use to measure the patient’s pulse rate before administering the cardiac medication Digoxin?

Which is the most important question for the nurse to ask the patient who has just arrived at the hospital with chest pain?

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?