-
During a physical assessment, the nurse observes that a client's blood pressure is 160/100 mmHg. What action should the nurse take?
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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is C
Explanation
Answer: c. Notify the healthcare provider of the significant difference.
Explanation: A significant difference in blood pressure readings between the right and left arms may indicate arterial occlusion or other circulatory abnormalities. The nurse should notify the healthcare provider for further evaluation and intervention.
a. Rechecking the blood pressure with a different cuff size may be appropriate if the initial readings were inaccurate, but it does not address the significant difference between the arms.
b. Documenting the finding is important, but further action is required to investigate the cause of the discrepancy.
d. Performing a Doppler ultrasound may be done as part of the diagnostic process to assess blood flow, but the healthcare provider should be notified first for appropriate evaluation.
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.