The nursing assistant informs the nurse that the patient's blood pressure is 220/102 using the electronic monitor. What is the priority action of the nurse?
Inform the patient's health care provider immediately to obtain an order for antihypertensive medications.
Instruct the nursing assistant to take the patient's blood pressure again and inform the nurse of the results immediately.
Take the patient's blood pressure manually with a sphygmomanometer and stethoscope.
Perform a neurological assessment to determine if the patient is stressed, in pain, or having a stroke.
The Correct Answer is C
A. Inform the patient's health care provider immediately to obtain an order for antihypertensive medications. While notifying the provider may be necessary, the nurse must first confirm the accuracy of the blood pressure reading before taking further action.
B. Instruct the nursing assistant to take the patient's blood pressure again and inform the nurse of the results immediately. Nursing assistants can take blood pressure readings, but the nurse should personally verify a critically high reading using a manual method.
C. Take the patient's blood pressure manually with a sphygmomanometer and stethoscope. Electronic monitors can sometimes give false readings, especially in patients with irregular heartbeats or movement. Manually verifying ensures an accurate assessment before determining further action.
D. Perform a neurological assessment to determine if the patient is stressed, in pain, or having a stroke. A neurological assessment is important if the elevated BP is confirmed, but the first priority is verifying the reading manually.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2"]
Explanation
Calculation:
Formula:
Tabletsperdose = Dose ordered/ Dose available
Given:
- Ordered dose = 100 mg
- Available dose = 50 mg per tablet
Tablets per dose = 100mg/ (50mg/tablet)
= 2 tablets
Thus, the nurse will administer 2 tablets per dose.
Correct Answer is B
Explanation
A. Positioning the bell very lightly over the patient's sternum. The bell is best for low-pitched sounds like murmurs, but heartbeats (especially S1 and S2) are better heard with the diaphragm over the apex of the heart, not the sternum.
B. Placing the diaphragm firmly against the patient's skin. The diaphragm is designed to pick up high-pitched sounds like the normal S1 and S2 heart sounds. Pressing firmly helps eliminate external noise and improves sound clarity.
C. Utilizing a stethoscope with the longest possible tubing. Longer tubing can reduce sound transmission quality. Shorter tubing (about 14-18 inches) provides clearer sound.
D. Making sure that the earpieces fit loosely in the nurse's ear canals. Earpieces should fit snugly, not loosely, to ensure optimal sound conduction and block external noise.
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