Name: Patricia Smithe
Provider: M. Pike, MD
Code Status: Full Code
Allergies: None known
Age: 74 years
Weight: 66.48 kg
Review the electronic health record. Which vital sign(s) should the nurse find concerning? Select all that apply.
|
Blood Pressure |
90/58 |
|
Oxygen Saturation |
97% on room air |
|
Pain |
1/10 right leg |
|
Temperature |
98.9 F(37.1 C) |
|
Heart Rate |
118 |
Respirations
Blood pressure
Pain
Heart rate
Temperature
Oxygen saturation
Correct Answer : B,D
A. The respiratory rate is not provided in the assessment data. Because no abnormal value is documented, respirations cannot be identified as concerning based on the available information. There is no evidence of tachypnea, bradypnea, or respiratory distress.
B. A blood pressure of 90/58 mmHg is hypotensive. In a 74-year-old client, hypotension is especially concerning because it may indicate decreased organ perfusion. Potential causes include dehydration, blood loss, sepsis, medication effects, or cardiac dysfunction. Older adults have decreased physiologic reserve, so low blood pressure increases the risk for dizziness, falls, syncope, kidney injury, and altered mental status. This finding requires immediate assessment.
C. A pain rating of 1/10 indicates minimal discomfort. This level of pain is mild and not physiologically destabilizing. It does not suggest acute distress or hemodynamic compromise and therefore is not a priority concern.
D. A heart rate of 118 beats per minute is tachycardia. Normal adult heart rate ranges from 60 to 100 beats per minute. Tachycardia in this context is concerning, especially when paired with hypotension. The elevated heart rate may represent a compensatory mechanism in response to low blood pressure in an attempt to maintain cardiac output and organ perfusion. This combination raises concern for early shock, hypovolemia, or other circulatory instability and requires prompt follow-up.
E. A temperature of 98.9°F (37.1°C) is within normal limits. There is no evidence of fever or hypothermia. This value does not indicate infection or systemic instability.
F. An oxygen saturation of 97% on room air is normal and indicates adequate oxygenation. There is no sign of hypoxia or respiratory compromise.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The difference between systolic and diastolic pressures is called the pulse pressure. It does not describe the systolic pressure itself. Pulse pressure is calculated by subtracting the diastolic pressure from the systolic pressure (e.g., 140 − 90 = 50 mmHg), but this is not the definition of systolic pressure.
B. This describes diastolic pressure, not systolic pressure. Diastolic pressure represents the lowest pressure in the arteries, occurring when the ventricles relax and fill with blood between heartbeats.
C. Blood pressure readings (systolic and diastolic) refer to arterial pressure, not venous pressure. Venous pressure is measured differently, typically via central venous pressure monitoring, and is not part of routine blood pressure assessment.
D. Systolic pressure reflects the maximum arterial pressure generated when the ventricles contract during systole, forcing blood into the aorta and systemic circulation. In this reading of 140/90 mmHg, the 140 mmHg represents the systolic pressure. Elevated systolic pressure can indicate hypertension, increased cardiac workload, or arterial stiffness and is a critical measurement in cardiovascular assessment.
Correct Answer is ["D","E"]
Explanation
A. The difference between the systolic and diastolic pressures is referred to as the pulse pressure, calculated by subtracting diastolic from systolic pressure (e.g., 140 – 90 = 50 mmHg). While pulse pressure provides useful information about arterial compliance and stroke volume, it does not define systolic pressure itself. Therefore, this statement does not reflect correct understanding of the systolic reading.
B. The pressure in the veins when the ventricles are contracting is incorrect. Venous pressure is generally low and does not fluctuate significantly with ventricular contraction, unlike arterial pressure. Systolic pressure is measured in the arteries, not veins, so this option demonstrates a misunderstanding.
C. The pressure in the veins when the ventricles are pushing blood forward is also incorrect for the same reason. Venous pressure is largely influenced by venous return and right atrial pressure, not the force of ventricular contraction. Systolic pressure refers exclusively to arterial pressure during ventricular contraction, not venous pressure.
D. The pressure in the arteries when the ventricles are pushing blood forward is correct. During ventricular systole, the left ventricle contracts, propelling blood into the aorta and systemic arteries, which creates the highest pressure in the arterial system. This peak arterial pressure is recorded as the systolic value in a blood pressure reading.
E. The pressure in the arteries when the ventricles are contracting is also correct. “Contracting” is another way of describing ventricular systole. Systolic pressure represents the maximum arterial pressure generated during this phase of the cardiac cycle, making this statement accurate.
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