The nurse is providing care for a client. The client’s blood pressure was 120/82 approximately 30 minutes ago. The current blood pressure is 88/50. What action by the nurse is the most appropriate?
Repeat the blood pressure in 30 minutes.
Document and continue to monitor.
Reassure the client that they are doing well.
Call the Rapid Response team.
The Correct Answer is D
Choice A reason: Repeating the blood pressure in 30 minutes is unsafe because the client’s blood pressure has dropped significantly in a short period. Waiting could delay life-saving interventions. Immediate action is required to address potential shock or cardiovascular collapse.
Choice B reason: Documenting and continuing to monitor is inappropriate because the client is showing signs of acute hypotension. Passive monitoring without intervention places the client at risk for deterioration. Documentation is important but must accompany urgent action.
Choice C reason: Reassuring the client that they are doing well is misleading and unsafe. The client’s blood pressure indicates a critical condition that requires immediate intervention. False reassurance could delay recognition of the seriousness of the situation.
Choice D reason: Calling the Rapid Response team is the most appropriate action. A sudden drop in blood pressure from 120/82 to 88/50 suggests possible shock, internal bleeding, or sepsis. Rapid Response teams are trained to provide immediate advanced interventions, stabilize the client, and prevent cardiac arrest. This action prioritizes patient safety and aligns with emergency protocols.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
Choice A reason: New onset of respiratory stridor indicates acute upper airway obstruction. Stridor is a high-pitched sound caused by turbulent airflow through a narrowed airway. This is a medical emergency because airway compromise can rapidly progress to respiratory failure. Immediate intervention is required to secure the airway and prevent hypoxia.
Choice B reason: Shortness of breath persisting for 20 minutes suggests significant respiratory distress. Prolonged dyspnea indicates impaired oxygenation or ventilation, which can quickly deteriorate if not addressed. This symptom requires immediate nursing action to assess oxygen saturation, provide supplemental oxygen, and notify the provider.
Choice C reason: A blood pressure of 150/84 is mildly elevated but not immediately life-threatening. Hypertension at this level does not require urgent intervention in the absence of other critical symptoms. It should be monitored and managed, but it does not demand immediate action compared to airway or severe acid-base disturbances.
Choice D reason: Nervousness associated with anxiety is not an urgent clinical finding. While anxiety can affect patient comfort and may exacerbate symptoms, it does not represent a life-threatening condition requiring immediate intervention. Supportive measures can be provided after stabilizing critical issues.
Choice E reason: ABG results showing pH 7.12, PaCO2 28 mmHg, and PaO2 55 mmHg indicate severe metabolic acidosis with hypoxemia. A pH of 7.12 reflects life-threatening acidemia, while PaO2 of 55 mmHg shows inadequate oxygenation. This combination requires immediate intervention to correct oxygenation and acid-base balance, as it can lead to cardiovascular collapse and multi-organ dysfunction if untreated.
Correct Answer is B
Explanation
Choice A reason: A decreased level of consciousness is not expected with sympathetic stimulation. Instead, sympathetic activation increases alertness and readiness for action. A reduction in consciousness would suggest adverse effects or another underlying condition, not the expected pharmacological response.
Choice B reason: Increased force of cardiac contraction is a hallmark of sympathetic nervous system stimulation. Sympathetic activation increases myocardial contractility and heart rate through catecholamine release, preparing the body for “fight or flight.” This is the correct expected manifestation.
Choice C reason: A decreased respiratory rate is not consistent with sympathetic stimulation. Instead, sympathetic activation typically increases respiratory rate to enhance oxygen delivery to tissues during stress or activity. A decrease would suggest depression of the respiratory system, which is more aligned with parasympathetic activity.
Choice D reason: Decreased blood pressure is not expected with sympathetic stimulation. Sympathetic activation causes vasoconstriction and increased cardiac output, leading to elevated blood pressure. A decrease would indicate parasympathetic dominance or circulatory collapse, not the intended effect of the medication.
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