The nurse is taking vital signs on a patient with a fractured femur. The blood pressure reading is 150/96. The patient does not have a history of hypertension. What action should the nurse take next?

Check the blood pressure in 90 minutes.

Call the health care provider and request an anti-anxiety medication.

Call the health care provider and request an antihypertensive.

Ask the patient if she is having pain.

Answer and Explanation

The Correct Answer is D

Choice A reason: Checking the blood pressure in 90 minutes delays addressing a potential cause of the elevated reading, such as pain from the fractured femur. Pain activates the sympathetic nervous system, increasing blood pressure. Immediate assessment of pain allows for timely intervention, preventing prolonged stress and ensuring accurate evaluation of the patient’s condition.

Choice B reason: Requesting anti-anxiety medication assumes anxiety is the cause without evidence. Pain from a fractured femur is a more likely trigger for elevated blood pressure, as it stimulates catecholamine release. Administering anxiolytics without assessing pain risks masking symptoms, delaying appropriate pain management, and failing to address the underlying physiological stressor.

Choice C reason: Requesting an antihypertensive is premature without identifying the cause of the elevated blood pressure. Pain from the fracture can cause transient hypertension via sympathetic activation. Treating the blood pressure without addressing pain may lower it unnecessarily, risking hypoperfusion while ignoring the primary issue, per pain management and cardiovascular physiology.

Choice D reason: Asking if the patient is having pain is the priority, as a fractured femur often causes significant pain, elevating blood pressure through sympathetic nervous system activation. Assessing pain guides appropriate analgesia, which may normalize blood pressure. This addresses the likely cause, aligns with patient-centered care, and prevents complications from untreated pain, per nursing assessment protocols.

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Correct Answer is D

Explanation

Choice A reason: Ambulatory tachycardia is not a recognized condition. Tachycardia (elevated heart rate) may occur with orthostatic changes but does not define the condition. Orthostatic hypotension, marked by a blood pressure drop (90/50 mmHg) upon standing, causes dizziness due to reduced cerebral perfusion from impaired vascular response, making this incorrect.

Choice B reason: Ambulatory bradycardia is not a standard term. Bradycardia (low heart rate) is unrelated to the symptoms of dizziness and low blood pressure (90/50 mmHg) upon standing. Orthostatic hypotension results from inadequate vasoconstriction and reduced venous return, decreasing cerebral blood flow, causing faintness, making this option incorrect.

Choice C reason: Orthostatic hypertension involves elevated blood pressure upon standing, opposite to the client’s 90/50 mmHg. Orthostatic hypotension, characterized by a drop in blood pressure, causes dizziness due to reduced cerebral perfusion from impaired baroreceptor-mediated vasoconstriction. This mismatch in symptoms and blood pressure response makes orthostatic hypertension incorrect.

Choice D reason: Orthostatic hypotension is a drop in blood pressure (e.g., 90/50 mmHg) upon standing, causing dizziness and faintness. It results from inadequate autonomic compensation, reducing venous return and cerebral perfusion. Post-surgical fluid shifts or autonomic dysfunction exacerbate this, impairing brain oxygenation, making this the correct term for the client’s condition.

A. Carotid B. Apical C. Radial D. Brachial

Correct Answer is A

Explanation

Choice A reason: The carotid pulse is used for unresponsive, non-breathing patients, as it is the most reliable central pulse, reflecting cardiac output during cardiac arrest. Its accessibility and strength make it ideal for rapid assessment, guiding CPR initiation, per ACLS and emergency assessment protocols.

Choice B reason: The apical pulse, assessed via auscultation, is impractical for an unresponsive, non-breathing patient, requiring time and equipment. In emergencies, the carotid pulse is faster and more reliable to confirm pulselessness, ensuring timely CPR, per cardiac arrest management guidelines.

Choice C reason: The radial pulse is peripheral and less reliable in cardiac arrest, as it may be absent due to poor perfusion. The carotid pulse better reflects central circulation, critical for assessing unresponsiveness and apnea, guiding immediate resuscitation efforts, per emergency care standards.

Choice D reason: The brachial pulse is used in infants or for blood pressure but is less accessible than the carotid in adults during arrest. The carotid provides a quick, reliable pulse check, ensuring rapid initiation of life-saving measures, per ACLS and pulse assessment protocols.

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The nurse is taking vital signs on a patient with a fractured femur. The blood pressure reading is 150/96. The patient does not have a history of hypertension. What action should the nurse take next?

Nursing Test Bank

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Correct Answer is D

Explanation

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Correct Answer is A

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