You are assessing a client who has the following vital signs: blood pressure 120/68, pulse 84, respirations 18. You should:
have another nurse recheck your findings for accuracy.
record the vital signs and compare them with previously charted vital signs.
report them to the charge nurse and call the doctor for orders.
instruct the client on diet and exercise for high blood pressure.
The Correct Answer is B
A. Have another nurse recheck your findings for accuracy. The vital signs are within normal limits, so there is no immediate need for validation by another nurse.
B. Record the vital signs and compare them with previously charted vital signs. The patient's blood pressure (120/68 mmHg), pulse (84 bpm), and respirations (18 breaths/min) are within normal ranges. The best action is to document the findings and compare them to previous values to identify any trends or changes.
C. Report them to the charge nurse and call the doctor for orders. Since the vital signs are normal, there is no need for immediate reporting or new medical orders.
D. Instruct the client on diet and exercise for high blood pressure. The blood pressure 120/68 mmHg is not high, so there is no need for immediate education on hypertension management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Always take the patient's blood pressure manually using a sphygmomanometer. While manual BP measurements can be more accurate, they are not the priority intervention for orthostatic hypotension, which primarily involves position changes and fall prevention.
B. Monitor the patient's neurological status carefully for symptoms of a stroke. Orthostatic hypotension can cause dizziness or fainting, but it is not a direct cause of stroke. Neurological assessment is important if symptoms arise but is not the primary intervention.
C. Assist the patient to sit and stand slowly when getting out of bed. Orthostatic hypotension causes a sudden drop in blood pressure upon standing, increasing the risk of falls and syncope. The priority action is to help the patient transition slowly from lying to sitting and standing to allow the body to adjust.
D. Check the patient's blood pressure on a lower extremity using a thigh-sized cuff. Lower extremity BP measurements are not standard for managing orthostatic hypotension. Blood pressure should be checked in both lying, sitting, and standing positions to monitor for significant drops.
Correct Answer is ["1.3"]
Explanation
Calculation:
Formula:
Dose to administer (mL) = Ordered dose (mcg) / Available dose (mcg/mL)
Given:
Ordered dose: 400 mcg.
Available dose: 300 mcg/mL.
Volume (mL) = 400 mcg / 300 mcg/mL
= 1.333... mL
Rounded to the nearest tenth: 1.3 mL.
The nurse will administer 1.3 mL of Neupogen.
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