The nurse measures the client’s blood pressure (BP) and notes that it is significantly higher than the previous reading. Which should the nurse do next? (Select all that apply)

Immediately take 2 more readings on the same arm.

Assign the unlicensed assistive personnel (UAP) to recheck the BP in an hour.

Retake the client’s blood pressure in the opposite arm.

Ask another nurse to assist in assessing for an apical-radial pulse deficit.

Determine the client’s activity and feelings prior to the BP measurement.

Answer and Explanation

Correct Answer : A,C,E

Choice A reason: Taking two more readings confirms elevated BP, as a single reading may reflect technique errors or transient factors like pain, which increase sympathetic activity and vasoconstriction. Multiple readings ensure accuracy, critical for diagnosing hypertension and guiding intervention to prevent cardiovascular complications like stroke.

Choice B reason: Assigning a UAP to recheck BP in an hour delays assessment of potentially dangerous hypertension, which risks acute complications like myocardial ischemia. Immediate confirmation is needed, as elevated BP from norepinephrine release increases vascular resistance, making delayed rechecking inappropriate for urgent evaluation.

Choice C reason: Retaking BP in the opposite arm verifies accuracy, as differences may indicate arterial occlusion. Elevated BP increases catecholamine-driven vascular resistance. Measuring both arms rules out localized issues, ensuring reliable data to guide management of hypertension, critical to prevent end-organ damage like renal failure.

Choice D reason: Assessing apical-radial pulse deficit is relevant for atrial fibrillation, not directly for elevated BP. Hypertension results from increased vascular resistance, not pulse discrepancies. Confirming BP and assessing context are more immediate to determine urgency, making this less relevant than verifying readings or identifying triggers.

Choice E reason: Determining activity and feelings identifies transient BP elevation causes, like stress or exercise, which raise norepinephrine, increasing heart rate and vascular tone. This contextualizes the reading, differentiating situational from chronic hypertension, ensuring appropriate intervention to manage cardiovascular risk and guide further assessment.

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Correct Answer is D

Explanation

Choice A reason: Delaying smoking for one hour is arbitrary and does not address smoking’s risks post-surgery. Nicotine causes vasoconstriction, reducing wound perfusion, and carbon monoxide impairs oxygen delivery, delaying healing. Advising against smoking mitigates these risks, promoting recovery, making this response less effective than cessation advice.

Choice B reason: Allowing smoking in a wheelchair ignores postoperative risks. Nicotine’s vasoconstriction reduces tissue oxygenation, and carbon monoxide lowers hemoglobin’s capacity, impairing healing. This increases infection or thrombosis risk. Advising against smoking addresses these physiological harms, prioritizing wound recovery over facilitating smoking, which is detrimental.

Choice C reason: Smoking in the room violates hospital safety and exposes others to secondhand smoke. Nicotine and carbon monoxide reduce tissue perfusion and oxygen delivery, delaying postoperative healing. Advising against smoking prevents these complications, ensuring better recovery, making this response unsafe and inappropriate for surgical patients.

Choice D reason: Advising against smoking is critical, as nicotine causes vasoconstriction, reducing blood flow to surgical sites, and carbon monoxide impairs oxygen delivery, delaying healing. These increase infection and thrombosis risks post-surgery. This response promotes optimal recovery, addressing physiological needs for wound healing in the critical 24-hour period.

A. Administer oxygen per nasal cannula. B. Remove objects that could cause injury. C. Place pillows around the client’s head. D. Apply soft restraints to all extremities.

Correct Answer is B

Explanation

Choice A reason: Administering oxygen supports oxygenation but is not the priority during a seizure, typically brief without sustained hypoxia. Removing objects prevents trauma from tonic-clonic movements, driven by neuronal hyperexcitability, addressing the immediate risk of fractures or head injuries during uncontrolled muscle activity.

Choice B reason: Removing objects prevents injury during a seizure, as tonic-clonic convulsions from excessive neuronal discharges risk trauma like fractures. Ensuring a safe environment addresses the physiological risk of harm from environmental hazards, critical for protecting the client during uncontrolled movements in seizure activity.

Choice C reason: Placing pillows around the head may reduce injury but is less effective than clearing hazards, as seizures involve full-body movements. Pillows may not stay secure during clonic jerking. Removing objects ensures broader safety, minimizing trauma risk across all body areas, making this less immediate.

Choice D reason: Applying restraints is contraindicated, as they risk injury like fractures by resisting forceful neuronal-driven movements. Seizures require safe movement in a clear environment. Removing objects prevents trauma, addressing the physiological need for safety during a seizure, making restraints inappropriate and potentially harmful.

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The nurse measures the client’s blood pressure (BP) and notes that it is significantly higher than the previous reading. Which should the nurse do next? (Select all that apply)

Nursing Test Bank

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