Which of these vital signs—BP would you report to the doctor?
90/60
125/68
144/76
150/70
The Correct Answer is A
Choice A reason: A blood pressure of 90/60 mmHg is hypotensive, indicating potentially inadequate perfusion to organs, which may result from dehydration, shock, or medication effects. This reading is concerning and requires reporting to the doctor for further evaluation and management to prevent complications like organ failure.
Choice B reason: A blood pressure of 125/68 mmHg is within normal to slightly elevated ranges, not immediately concerning. It does not warrant urgent reporting unless accompanied by symptoms or trends suggesting instability, as it aligns with typical adult values under most clinical guidelines.
Choice C reason: A blood pressure of 144/76 mmHg is elevated but not critical unless persistent or symptomatic. It suggests prehypertension or early hypertension, which may need monitoring but not immediate reporting unless other clinical factors, like symptoms or patient history, indicate urgency.
Choice D reason: A blood pressure of 150/70 mmHg is elevated, indicating possible hypertension, but not an emergency unless accompanied by symptoms like chest pain. It requires monitoring rather than immediate reporting, as it falls short of hypertensive crisis thresholds like 180/120 mmHg.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: The descending colon is located in the left lower quadrant (LLQ), descending along the left abdomen. Assessing this area detects abnormalities like diverticulitis or masses. Accurate localization ensures targeted examination, guiding diagnosis and interventions, critical for managing colorectal conditions and preventing complications in abdominal assessments.
Choice B reason: The right lower quadrant (RLQ) contains the appendix and cecum, not the descending colon, which is in the LLQ. Misidentifying this risks incorrect assessment, potentially missing LLQ issues like colitis, delaying diagnosis and treatment, critical for addressing colorectal pathology in patients with abdominal symptoms.
Choice C reason: The right upper quadrant (RUQ) includes the liver and gallbladder, not the descending colon, located in the LLQ. Assuming RUQ misguides assessment, risking oversight of LLQ conditions like diverticulitis, delaying targeted interventions, essential for accurate diagnosis and management of abdominal issues in clinical practice.
Choice D reason: The left upper quadrant (LUQ) contains the stomach and spleen, not the descending colon, which resides in the LLQ. Misidentifying this risks missing LLQ pathology like masses or inflammation, delaying diagnosis and treatment, critical for effective abdominal assessment and management of colorectal conditions in patients.
Correct Answer is A
Explanation
Choice A reason: Assessment in the nursing process involves collecting subjective and objective data via interviews, physical exams, and observations to inform clinical judgments. This foundational step identifies patient needs, guiding subsequent planning. Accurate data collection ensures comprehensive care, preventing oversight of critical health issues and supporting effective diagnosis and intervention in clinical practice.
Choice B reason: Using problem-solving to prioritize outcomes and develop interventions describes the planning step, not assessment. Assessment focuses on data collection, not goal-setting. Assuming this misaligns with the nursing process, risking premature intervention without thorough data, which could lead to ineffective care plans or missed health issues in patient management.
Choice C reason: Assessing goal effectiveness and adjusting interventions pertains to the evaluation step, not assessment. Assessment gathers data to identify needs, not evaluate outcomes. Misidentifying this risks skipping data collection, leading to incomplete assessments and inappropriate interventions, compromising patient safety and care quality in the nursing process.
Choice D reason: Using clinical judgment to formulate problems is part of diagnosis, not assessment. Assessment collects raw data, while diagnosis analyzes it to identify issues. Assuming this conflates steps, risking incomplete data collection, which could result in inaccurate diagnoses and ineffective care plans, undermining the systematic approach of the nursing process.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.