The nursing assistive personnel (NAP) is taking vital signs and reports that a patient's blood pressure abnormally low. What should the nurse do next?
Ask the NAP retake the blood pressure.
Instruct the NAP to assess the patient's other vital signs.
Disregard the report and have it rechecked at the next scheduled time.
Retake the blood pressure personally and assess the patient's condition.
The Correct Answer is D
A. Ask the NAP to retake the blood pressure:
While possible, the nurse is responsible for verifying abnormal findings and interpreting their significance.
B. Instruct the NAP to assess the patient's other vital signs:
NAPs can measure vitals but cannot interpret findings or perform assessments.
C. Disregard the report and have it rechecked at the next scheduled time:
Ignoring potentially critical information endangers the patient.
D. Retake the blood pressure personally and assess the patient’s condition:
This is correct. The nurse must validate and assess any abnormal findings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Right medication:
Giving the correct drug is important, but without confirming identity, it may be given to the wrong person.
B. Right patient:
This is the priority in this scenario where two patients have the same last name. Confirming identity using two identifiers (e.g., name and birth date) is critical.
C. Right dose:
A correct dose is important, but it assumes it’s given to the right patient.
D. Right route:
Administering via the correct route is essential but irrelevant if the wrong patient receives the drug.
Correct Answer is D
Explanation
A. Disconnect the drainage tube from the catheter:
This breaks the closed system and increases the risk of infection. Not appropriate.
B. Withdraw urine from the closed system drainage bag:
The urine in the bag is not fresh and may be contaminated, leading to inaccurate results.
C. Empty contents of the drainage bag into the specimen cup:
This is not a sterile method and would not provide a reliable culture result.
D. Attach a sterile syringe to the catheter port to withdraw urine:
This is the correct sterile technique for obtaining a sample from an indwelling catheter without contaminating the system.
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