Which assessment requires the nurse to assess the patient further?

40-year-old with a pulse of 88

18-year-old with a pulse rate of 140 after riding 2 miles on an exercise bike

50-year-old man with a BP of 112/60 mmHg on awakening in the morning

65-year-old with a respiratory rate of 10/min

Answer and Explanation

The Correct Answer is D

A. 40-year-old with a pulse of 88. A resting pulse of 88 beats per minute is within the normal adult range (60–100 bpm) and does not require further assessment.
B. 18-year-old with a pulse rate of 140 after riding 2 miles on an exercise bike. An increased heart rate after exercise is a normal physiological response, and the heart rate should return to baseline after rest. No further assessment is needed unless tachycardia persists.
C. 50-year-old man with a BP of 112/60 mmHg on awakening in the morning. This blood pressure is within a normal range, especially in the early morning when BP is often lower. No additional assessment is required.
D. 65-year-old with a respiratory rate of 10/min. A normal respiratory rate for an adult is 12–20 breaths per minute. A respiratory rate of 10 is lower than normal and may indicate respiratory depression, which could be caused by medications such as opioids, neurological issues, or other conditions requiring further evaluation.

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Correct Answer is A

Explanation

A. "The top number is the systolic blood pressure and reflects the pressure on the arteries when the heart contracts." The systolic pressure (118 mmHg) represents the force exerted on the arterial walls when the heart contracts and pumps blood.
B. "The numbers are within normal range and nothing to worry about." While 118/82 mmHg is within the normal range, this response does not explain what the numbers mean, which was the patient’s question.
C. "The concept of blood pressure is difficult to understand. The main thing to be concerned about is the top number, or systolic blood pressure." While the systolic pressure is important, the diastolic pressure is also crucial for assessing cardiovascular health. This response also discourages patient education.
D. "The bottom number is the diastolic pressure and reflects the stroke volume of the heart." Diastolic pressure (82 mmHg) represents the pressure in the arteries when the heart is at rest, not stroke volume, which refers to the amount of blood ejected per heartbeat.

Correct Answer is ["10"]

Explanation

To convert teaspoons (tsp) to milliliters (mL), the conversion factor is:

1tsp=5mL1

Given:

2 tsp

2 × 5mL = 10mL

Thus, 2 tsp = 10 mL.

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Which assessment requires the nurse to assess the patient further?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Your patient's blood pressure is 118/82. He asks you to explain "what the numbers mean." You reply:

Correct Answer is A

Explanation

2 tsp =

Correct Answer is ["10"]

Explanation

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