During admission of an obese patient with heart failure the assistive personnel (AP) reports to the nurse that the blood pressure (BP) is 140/76 on the left arm and 128/72 on the right arm. What actions do you take on the basis of this information? Select all that apply
Notify the health care provider immediately.
Repeat the measurements on both arms using a stethoscope.
Ask the patient whether she has taken her blood pressure medications recently.
Obtain blood pressure measurements on lower extremities.
Review the patient’s record for her baseline vital signs.
Correct Answer : B,E
A difference in blood pressure readings between arms can be a normal variation (up to 10 mm Hg) or a sign of vascular disease such as subclavian artery stenosis, aortic dissection, or peripheral arterial disease.
Rationale for correct answers:
B. Repeat the measurements on both arms using a stethoscope: The AP may have used an automated cuff, which can be less accurate in obese patients or those with arrhythmias.
E. Review the patient’s record for her baseline vital signs: Comparing with previous BP readings helps determine whether the difference is new, worsening, or chronic.
Rationale for incorrect answers:
A. Notify the health care provider immediately: A 12 mm Hg systolic difference may warrant further evaluation if persistent, but notifying the provider immediately is premature.
C. Ask the patient whether she has taken her blood pressure medications recently: BP medication doesn’t cause a discrepancy between the two limbs.
D. Obtain blood pressure measurements on lower extremities: Lower extremity BP may be needed if there is suspicion of aortic coarctation or severe vascular disease, but this is not routinely indicated for a 12 mm Hg arm difference.
Take-home points:
- A systolic BP difference of >10 mm Hg between arms should be manually verified and assessed in context of clinical history and baseline.
- Nurses must take a stepwise approach-recheck manually, gather history, review baseline-before escalating to a provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
Postoperative patients, especially those with heart failure, are at increased risk for orthostatic hypotension due to bedrest, anesthetic effects, and volume shifts. Orthostatic intolerance may manifest as dizziness, nausea, or fainting when the client is moved from lying to sitting or standing.
Rationale for correct answers:
A. Lower the head of the bed and return the patient to the supine position: This is the first and most important safety step to prevent fainting or falls. Returning to a supine position helps restore cerebral perfusion, relieving dizziness.
B. Obtain vital signs: Vital signs (especially blood pressure and heart rate) should be obtained to assess for orthostatic hypotension or other hemodynamic instability.
D. Allow the patient to rest for 20 to 30 minutes: After returning to a safe position, resting allows stabilization of blood pressure and heart rate. Many patients tolerate activity better after a brief rest period.
E. Raise the head of the bed again and obtain blood pressure readings: Gradually raising the head of the bed and monitoring orthostatic BPs is part of safely assessing tolerance to positional changes.
Rationale for incorrect answer:
C. Encourage the patient to try to sit on the side of the bed and then stand: Encouraging further movement while the patient is symptomatic is unsafe. Doing so may worsen symptoms and risk falls or cardiovascular collapse.
Take-home points:
- Immediate safety actions (return to supine, assess vitals) are essential when a patient becomes dizzy with movement.
- Orthostatic BP monitoring and gradual progression to activity can help prevent falls and guide safe ambulation.
Correct Answer is A
Explanation
The Point of Maximal Impulse (PMI), also referred to as the apical impulse, is the location on the chest wall where the heartbeat is most strongly felt or heard. It corresponds to the apex of the heart, typically located at the 5th intercostal space, midclavicular line in adults
Rationale for correct answers:
E. Near apex: This point corresponds to the 5th intercostal space at the midclavicular line, where the apex of the heart contacts the chest wall. It is the most accurate site for auscultating the apical pulse and evaluating left ventricular function.
Rationale for incorrect answers:
A. To the right of the aorta. This is in the right upper sternal border, typically used to auscultate the aortic valve area. It is not associated with the PMI or apex of the heart.
B. At left atrium: This is positioned more posteriorly in the chest and not palpable or auscultated directly from the anterior chest wall.
C. Placed slightly below 2: Still in the left parasternal area, likely over the pulmonic or tricuspid area, but not the apex.
D. Placed slightly below 3: This is near the left lower sternal border, where tricuspid sounds may be heard, but it's still not the apex.
F. At xiphoid process: This is the epigastric area, well below the heart’s apex, and is not used to assess apical pulse or PMI.
Take-home points:
- The PMI is best auscultated at the 5th intercostal space, midclavicular line, which corresponds to point 5 in the diagram.
- Accurate location of the PMI is essential in assessing left ventricular function and detecting cardiac enlargement or displacement.
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