The nurse is teaching the community about blood pressure. What blood pressure finding by the nurse indicates that no changes in therapy are needed for a client with newly diagnosed hypertension?

128/76 mm Hg

128/92 mm Hg

98/56 mm Hg

142/78 mm Hg

Answer and Explanation

The Correct Answer is A

Hypertension is typically diagnosed when a person's blood pressure consistently exceeds 130/80 mm Hg on multiple occasions. However, the specific target blood pressure for treatment may vary based on individual factors and the presence of other comorbidities.

Among the options provided, a blood pressure reading of 128/76 mm Hg is within the target range for many individuals with hypertension. The systolic pressure (128 mm Hg) is below the threshold of 130 mm Hg, and the diastolic pressure (76 mm Hg) is below the threshold of 80 mm Hg.

The other blood pressure readings would warrant further evaluation or possible changes in therapy:

128/92 mm Hg: The diastolic pressure (92 mm Hg) is above the threshold of 80 mm Hg, indicating uncontrolled hypertension.

98/56 mm Hg: This blood pressure reading is below the threshold for hypertension, but it is considered low and may require further assessment to determine if it is normal for the individual or if it indicates hypotension.

142/78 mm Hg: While the systolic pressure (142 mm Hg) is slightly above the threshold of 130 mm Hg, it may not necessarily require immediate changes in therapy. However, it should be closely monitored to ensure blood pressure control.

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Correct Answer is D

Explanation

Transesophageal echocardiography is a diagnostic procedure that involves inserting a probe into the esophagus to obtain detailed images of the heart. In some cases, an access line may be initiated in the femoral artery to monitor blood pressure during the procedure and administer medications if needed. Informing the client about this aspect of the procedure helps ensure that they are aware of what to expect and can provide informed consent.

Let's go through the other options and explain why they are not the most appropriate actions:

Instruct the client to drink 1 L of water before the test: This action is not necessary for transesophageal echocardiography. Drinking water before the test is typically done for certain abdominal or pelvic ultrasound examinations to provide better visualization. However, for TEE, the probe is inserted into the esophagus, and drinking water is not required.

Administer intravenous (IV) benzodiazepines and opioids: The administration of intravenous benzodiazepines and opioids is not a routine part of preparing a client for TEE. The need for sedation or analgesia during the procedure would be determined based on the individual client's condition and level of discomfort.

Inform the client that the client will remain on bed rest following the procedure: While some post-procedure instructions may be given to the client, such as avoiding eating or drinking until the effects of sedation wear off, informing the client that they will remain on bed rest following the procedure is not a speciﬁc requirement for TEE. Post-procedure instructions can vary depending on the individual client's condition and the healthcare provider's recommendations.

A. Wrap both legs in a warming blanket B. Compare ﬁndings to the preoperative assessment of the pulses C. Document the ﬁndings and recheck in 15 minutes. D. Notify the surgeon and anesthesiologist

Correct Answer is D

Explanation

The nurse should prioritize notifying the surgeon and anesthesiologist as the ﬁrst action. The absent pulses, coolness, and mottled appearance of the leg indicate potential compromised blood ﬂow to the lower extremity, which could be a sign of vascular compromise or acute limb ischemia. These ﬁndings are concerning after the repair of an abdominal aortic aneurysm and require immediate medical attention.

Wrap both legs in a warming blanket: While it is important to maintain the client's body temperature, this action alone may not address the underlying issue of compromised blood ﬂow and potential limb ischemia. Notifying the surgeon and anesthesiologist is the priority to address the immediate concern.

Compare ﬁndings to the preoperative assessment of the pulses: While comparing ﬁndings to the preoperative assessment is important for evaluating the client's condition, it should not delay immediate action. The priority in this situation is to promptly notify the surgeon and anesthesiologist to address the potential vascular compromise.

Document the ﬁndings and recheck in 15 minutes: Documenting the ﬁndings is an important step in the nursing process, but it should not take precedence over immediate intervention. The concerning signs of absent pulses, coolness, and mottled appearance require urgent attention, and delaying notiﬁcation could lead to further complications.

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The nurse is teaching the community about blood pressure. What blood pressure finding by the nurse indicates that no changes in therapy are needed for a client with newly diagnosed hypertension?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing a client for scheduled transesophageal echocardiography. Which action should the nurse perform?

Correct Answer is D

Explanation

The nurse is caring for a client immediately after repair of an abdominal aortic aneurysm. On assessment, the client has absent popliteal, posterior tibial, and dorsalis pedis pulses. The leg cool and mottled. Which action should the nurse take ﬁrst?

Correct Answer is D

Explanation

The nurse is caring for a client with hypertension who is on alpha blockers. The nurse is concerned about postural hypotension. Which information should the nurse include in the teaching plan?

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The nurse is teaching the community about blood pressure. What blood pressure finding by the nurse indicates that no changes in therapy are needed for a client with newly diagnosed hypertension?

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