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 ["1.5"]
Explanation
Calculation:
Volume to administer = Dose ordered/ Dose available
Given:
- Ordered dose = 75 mg
- Available concentration = 50 mg/mL
Volume = 75mg/ (50mg/mL)
= 1.5mL
Thus, the nurse will administer 1.5 mL.
Correct Answer is C
Explanation
A. Auscultation. Auscultation involves listening to internal body sounds, usually with a stethoscope, such as heart, lung, or bowel sounds. It is not used for assessing the radial pulse.
B. Percussion. Percussion is the technique of tapping on body surfaces to assess underlying structures, such as detecting fluid in the lungs or assessing organ size. It is not used to assess pulses.
C. Palpation. Palpation involves using the fingers to feel for the radial pulse by applying gentle pressure over the radial artery at the wrist. This is the correct method for assessing a patient's radial pulse.
D. Inspection. Inspection involves visually examining the patient for abnormalities such as skin color, swelling, or deformities. It does not provide information about pulse rate or rhythm.
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