An assistive personnel (AP) reports the following vital signs for your patient: temperature 98.8 F, pulse 92/min, respiratory rate 18/min, and BP 98/58 mm Hg. Which of the following vital signs should the nurse re-measure?
Pulse rate.
Respiratory rate.
Blood pressure.
Temperature.
The Correct Answer is C
Choice A rationale
The reported pulse rate of 92 beats per minute falls within the expected reference range for a healthy adult, which is typically between 60 and 100 beats per minute. Because this value is hemodynamically stable and normal, there is no immediate physiological indication that the nurse needs to re-measure it. The AP's finding is consistent with a resting state, and unless the patient is symptomatic or has a specific cardiac history, this measurement is accepted.
Choice B rationale
The respiratory rate of 18 breaths per minute is within the normal adult range of 12 to 20 breaths per minute. This finding indicates that the patient is likely ventilating adequately without acute distress. Since the value is not tachypneic or bradypneic, re-measurement is not a priority. The nurse should continue to observe the patient's work of breathing and oxygen saturation, but the reported rate itself does not necessitate an immediate verification by the licensed nurse.
Choice C rationale
The reported blood pressure of 98/58 mm Hg is considered low, as a typical normal reading is approximately 120/80 mm Hg. Hypotension, generally defined as a systolic pressure below 90 mm Hg or a significantly low diastolic pressure, requires professional verification to ensure patient safety and clinical accuracy. The nurse must assess for signs of decreased organ perfusion, such as dizziness or confusion, and confirm the reading before making interventions or notifying the provider about the status.
Choice D rationale
A temperature of 98.8 F is well within the normal afebrile range for an adult, which usually spans from 96.4 F to 99.1 F. Since this reading does not indicate a fever or hypothermia, there is no clinical reason to doubt the AP's measurement or to perform a repeat assessment. The patient’s thermoregulation appears intact, and the nurse can move on to addressing more concerning vital signs, such as the low blood pressure reported in the set.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
A blood pressure of 128/80 mmHg is considered within the normal to slightly elevated range according to current cardiovascular guidelines. Normal blood pressure is generally defined as less than 120/80 mmHg. Lisinopril, an ACE inhibitor, is indicated for hypertension and would typically be administered at this level to maintain therapeutic control. There is no clinical indication of hypotension at this reading, so holding the medication would be inappropriate for this client.
Choice B rationale
A blood pressure of 146/70 mmHg indicates isolated systolic hypertension. The systolic pressure is significantly above the target range of less than 120 mmHg. Administering lisinopril is necessary here to reduce systemic vascular resistance and lower the blood pressure toward a safer therapeutic goal. Holding the medication at this level would allow the hypertension to persist, increasing the risk of long-term vascular damage or acute cardiac events for the client.
Choice C rationale
A blood pressure of 102/58 mmHg is nearing the threshold for hypotension, which is generally defined as a systolic pressure less than 90 mmHg or a diastolic less than 60 mmHg. For a client on antihypertensives like lisinopril, this low reading suggests that further vasodilation could cause symptomatic hypotension or decreased organ perfusion. The nurse should hold the dose and notify the provider to prevent a dangerous drop in blood pressure and syncope.
Choice D rationale
A reading of 110/82 mmHg is considered a normal or pre-hypertensive blood pressure. It does not meet the criteria for hypotension that would warrant holding a scheduled cardiac medication. Lisinopril works by inhibiting the angiotensin-converting enzyme, which prevents the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor. At 110/82 mmHg, the client is stable, and the medication is likely working effectively to maintain these desired cardiovascular parameters.
Correct Answer is D
Explanation
Choice A rationale
Corn is a starchy vegetable that provides some nutrients but is not considered a high-potassium food source. In the management of hypokalemia, where serum potassium levels are below 3.5 mEq/L, the focus is on incorporating foods with high concentrations of the cation. While corn contains approximately 270 mg of potassium per cup, it is significantly less dense in this electrolyte compared to other vegetables. It does not provide the robust replacement needed for high-risk clients.
Choice B rationale
Cucumbers consist mostly of water and fiber but are relatively low in potassium content. One cup of sliced cucumbers provides only about 150 mg of potassium, which is insufficient for effectively raising serum levels in a client at risk for hypokalemia. While healthy for hydration, they are not the therapeutic choice for electrolyte replacement. Dietitians prioritize foods that offer a higher milligram-to-volume ratio of potassium to ensure that the patient meets the necessary daily intake goals.
Choice C rationale
Asparagus is a nutritious vegetable containing various vitamins and minerals, providing roughly 200 mg of potassium per serving. While it is better than some other low-potassium options, it still falls short of being a primary dietary recommendation for treating low potassium. Clients needing to increase their potassium intake are encouraged to consume foods that provide a more substantial boost per serving. It is a healthy addition but not the most potent choice for electrolyte management.
Choice D rationale
Tomatoes are an excellent source of potassium and are highly recommended for clients at risk for hypokalemia. A single cup of tomato juice or a large tomato can provide over 400 mg of potassium, which helps maintain serum levels within the normal range of 3.5 to 5.0 mEq/L. Increasing intake of potassium-rich foods like tomatoes helps support cardiac electrical conductivity and muscle contraction. This makes them a vital dietary component for preventing the complications of low potassium.
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