The nurse is caring for a hypotensive patient whose peripheral pulses are very weak. Which grade will the nurse use to document this finding?
4+
3+
2+
1+
The Correct Answer is D
A. 4+. A 4+ pulse is bounding and strong, often seen in conditions like fever, anemia, or fluid overload. This does not match the description of a weak pulse.
B. 3+. A 3+ pulse is stronger than normal but not bounding. This is not considered weak.
C. 2+. A 2+ pulse is normal and easily palpable, which does not indicate the weakened pulse described in the patient.
D. 1+. A 1+ pulse is weak and thready, meaning it is difficult to palpate and easily disappears with slight pressure. This grading is appropriate for a hypotensive patient with poor perfusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.5"]
Explanation
To determine the number of tablets per dose, use the formula:
Tablets per dose = Dose ordered/Dose available
Given:
- Ordered dose = 400 mg
- Available dose = 800 mg per tablet
Tablets per dose = 400mg/(800mg/tablet)
= 0.5 tablet
Thus, the nurse will administer 0.5 tablet per dose.
Correct Answer is C
Explanation
A. Always take the patient's blood pressure manually using a sphygmomanometer. While manual BP measurements can be more accurate, they are not the priority intervention for orthostatic hypotension, which primarily involves position changes and fall prevention.
B. Monitor the patient's neurological status carefully for symptoms of a stroke. Orthostatic hypotension can cause dizziness or fainting, but it is not a direct cause of stroke. Neurological assessment is important if symptoms arise but is not the primary intervention.
C. Assist the patient to sit and stand slowly when getting out of bed. Orthostatic hypotension causes a sudden drop in blood pressure upon standing, increasing the risk of falls and syncope. The priority action is to help the patient transition slowly from lying to sitting and standing to allow the body to adjust.
D. Check the patient's blood pressure on a lower extremity using a thigh-sized cuff. Lower extremity BP measurements are not standard for managing orthostatic hypotension. Blood pressure should be checked in both lying, sitting, and standing positions to monitor for significant drops.
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