The nurse identifies that the patient care tech recorded the client's blood pressure as 78/52. The nurse recognizes this blood pressure is abnormally low for this client. What is the best response by the nurse?

Reassess the blood pressure measurement.

Notify the provider.

Recheck the blood pressure measurement in 30 minutes.

Have the patient care tech take the blood pressure measurement again.

Answer and Explanation

The Correct Answer is A

A. Reassessing the blood pressure measurement is correct because the nurse should always verify abnormal findings before taking further action. The initial reading could be due to equipment error, improper cuff size, or patient positioning.
B. Notifying the provider is incorrect at this time because the nurse should first confirm the accuracy of the reading before escalating concerns.
C. Rechecking the BP in 30 minutes is incorrect because if the reading is accurate, waiting 30 minutes could delay necessary interventions.
D. Having the patient care tech take the BP again is incorrect because the nurse should personally validate the abnormal finding rather than delegating it.

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Correct Answer is B

Explanation

A. While documentation does satisfy legal standards, the primary reason for documenting the initial assessment is to guide the entire nursing process.
B. "Documentation of the initial assessment becomes the foundation for the entire nursing process" is correct because all subsequent care planning, interventions, and evaluations depend on accurate initial assessment data.
C. Documentation should be objective, not based on the nurse’s opinions.
D. Institutional policies are important, but the significance of initial assessment documentation lies in its role in guiding patient care.

A. Understanding of the referral process. B. Recognition of the client's medical prognosis. C. Drawing inferences about the client. D. Knowledge of anatomy and physiology.

Correct Answer is C

Explanation

A. Understanding the referral process is important for coordinating care but is not required to identify abnormal data and client strengths.
B. While knowing the medical prognosis can provide context, the nursing process focuses on holistic client assessment rather than medical diagnosis.
C. Drawing inferences about the client is correct because analyzing the collected data allows the nurse to recognize patterns, identify potential health problems, and determine the client’s strengths.
D. Knowledge of anatomy and physiology is valuable, but interpretation and clinical judgment (drawing inferences) are crucial for identifying abnormal data.

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The nurse identifies that the patient care tech recorded the client's blood pressure as 78/52. The nurse recognizes this blood pressure is abnormally low for this client. What is the best response by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following statements indicate that the student nurse understands the importance of documenting the initial assessment data?

Correct Answer is B

Explanation

A nurse has completed the client's initial assessment and is preparing to identify abnormal data and the client's strengths. Which of the following is required to successfully complete this phase of the nursing process?

Correct Answer is C

Explanation

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