The nurse is caring for a patient with the following vital signs:
- Temperature: 98.9° F
- Pulse: 94
- Respirations: 20
- Blood pressure: 144/94
- Pulse oximetry: 94%
What is the priority action of the nurse?
Document the findings in the patient's medical record.
Apply a cool washcloth to the patient's forehead.
Administer oxygen at 2 U/minute via nasal cannula.
Ask the patient about his usual blood pressure results.
The Correct Answer is D
A. Document the findings in the patient's medical record. While documentation is important, further assessment is needed before determining if the blood pressure is abnormal for this patient.
B. Apply a cool washcloth to the patient's forehead. The patient’s temperature is normal (98.9°F), so there is no need for cooling measures.
C. Administer oxygen at 2 L/minute via nasal cannula. The pulse oximetry is 94%, which is adequate for most patients. Oxygen is not needed unless the patient shows signs of respiratory distress.
D. Ask the patient about his usual blood pressure results. The blood pressure (144/94 mmHg) is elevated, but before determining if intervention is needed, the nurse should ask if this is typical for the patient or if it is an isolated finding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Have the patient drink hot liquids. An unconscious patient cannot safely swallow, and forcing fluids could lead to aspiration. Additionally, internal warming should be done cautiously to avoid complications like shock.
B. Bathe the patient to promote shivering. Shivering is the body’s natural response to generate heat, but bathing a hypothermic patient would further lower body temperature and worsen the condition.
C. Remove restrictive items of clothing. While removing wet or restrictive clothing is important, it is not the priority over actively warming the patient. Hypothermia management focuses on gradual rewarming.
D. Wrap the patient in warmed blankets. The priority in hypothermia is gradual external rewarming using warmed blankets to prevent further heat loss and safely increase body temperature.
Correct Answer is A
Explanation
A. The patient's blood pressure must remain elevated during several separate assessments in order to make a diagnosis of hypertension. Hypertension is diagnosed based on persistently elevated blood pressure readings across multiple visits, rather than a single elevated measurement.
B. The patient appeared extremely stressed and the health care provider decided not to inform the patient of the diagnosis at that appointment. While stress can temporarily elevate blood pressure, a diagnosis should be based on multiple readings rather than withholding information from the patient.
C. The patient's primary health care provider must consult with a cardiologist in order to make a diagnosis of hypertension. A cardiology consult is not required to diagnose hypertension; primary care providers can diagnose and manage hypertension independently.
D. The patient's blood pressure must be at least 180/100 during a single assessment in order for a diagnosis of hypertension to be made. A reading of 180/100 mmHg indicates hypertensive crisis, but hypertension is diagnosed when blood pressure is consistently ≥140/90 mmHg on multiple occasions.
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