During a physical assessment, the nurse observes that a client's blood pressure is 160/100 mmHg. What action should the nurse take?

Recheck the blood pressure using a different cuff size.

Document the blood pressure findings as the only action required.

Administer an antihypertensive medication immediately.

Notify the healthcare provider of the elevated blood pressure.

Answer and Explanation

The Correct Answer is D

Answer: d. Notify the healthcare provider of the elevated blood pressure.

Explanation: A blood pressure reading of 160/100 mmHg indicates hypertension and requires further evaluation by the healthcare provider to determine appropriate management.

a. Rechecking the blood pressure with a different cuff size may be appropriate if the initial reading was inaccurate, but it does not address the elevated blood pressure result.

b. Documenting the finding is important, but further action is required for elevated blood pressure.

c. Administering antihypertensive medication without consulting the provider is not appropriate; medication decisions should be made by the healthcare provider.

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Correct Answer is C

Explanation

Answer: c. Swipe the thermometer gently across the client's forehead.

Explanation: Temporal artery thermometers are used by swiping the thermometer gently across the client's forehead. The device measures the temperature of the temporal artery, which correlates with core body temperature.

a. Inserting the thermometer into the rectum is not the appropriate method for using a temporal artery thermometer.

b. Placing the thermometer in the axilla is appropriate for axillary temperature measurement but not for temporal artery thermometers.

d. Holding the thermometer under the tongue is appropriate for oral temperature measurement but not for temporal artery thermometers.

A. Document the finding as a normal variation. B. Reapply the pulse oximeter on a different finger. C. Assess the client for signs of respiratory distress. D. Notify the healthcare provider of the irregular waveform. Answer: b. Reapply the pulse oximeter on a different finger.

Correct Answer is B

Explanation

indicate poor sensor placement or a faulty pulse oximeter. The nurse should reapply the pulse oximeter on a different finger to obtain an accurate reading.

a. An irregular waveform is not a normal variation and should be investigated further.

c. Assessing the client for signs of respiratory distress is important but may not directly address the irregular waveform.

d. Notifying the healthcare provider may be necessary if the issue persists after reapplying the pulse oximeter.

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During a physical assessment, the nurse observes that a client's blood pressure is 160/100 mmHg. What action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client's body temperature using a temporal artery thermometer. How should the nurse use the temporal artery thermometer?

Correct Answer is C

Explanation

A nurse is assessing a client's pulse oximetry reading and notices that the waveform is irregular and inconsistent. What action should the nurse take?

Correct Answer is B

Explanation

A nurse is assessing a client's respiratory rate and finds it to be 8 breaths per minute. What action should the nurse take first?

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