-
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 D
Explanation
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.
Correct Answer is D
Explanation
Explanation: A respiratory rate of 8 breaths per minute is significantly below the normal range (12-20 breaths per minute), indicating potential respiratory distress. The nurse should perform a thorough respiratory assessment to gather more information and determine appropriate interventions.
a. Administering oxygen may be necessary, but the nurse should first assess the client's respiratory status before initiating any interventions.
b. Placing the client in a supine position is not indicated and may worsen respiratory distress in some situations.
c. Reassessing after 1 hour is not appropriate when a client is experiencing abnormal vital signs; immediate action is needed.
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.