A 45-year-old patient who is alert and oriented has a blood pressure of 98/66 mm Hg, radial pulse of 76 beats/min (irregular), and respirations of 18 breaths/min (regular). The best nursing intervention is to:
check the patient's record to determine his baseline blood pressure.
notify the charge nurse of the hypotension.
check medications that might be the cause of the irregularity.
notify the doctor of the bradycardia.
The Correct Answer is A
A. This is because the patient's blood pressure of 98/66 mm Hg, while on the lower side, may be normal for them. It's important to compare it to their baseline to determine if there has been a significant change.
B. The blood pressure is within a normal range for an adult, so immediate notification of hypotension is not required.
C. This can be done after determining if there is a significant change from the baseline.
D. The pulse is not bradycardic (it is within a normal range), so there is no immediate need to notify the doctor regarding bradycardia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
A persistent cough can indicate lung cancer or other types of cancer affecting the respiratory system, making it a warning sign that should be noted.
B. Difficulty swallowing, or dysphagia, can be indicative of cancer in the esophagus, throat, or mouth, and should raise concern when observed.
C. Changes in pulse rate are typically not direct indicators of cancer; however, they could result from underlying conditions related to cancer treatment or progression.
D. An obvious change in a mole, especially in size, shape, or color, is a well-known warning sign of skin cancer, specifically melanoma.
E. Vesicular breath sounds are normal breath sounds, not linked to cancer.
F. Hyperactive bowel sounds could indicate a gastrointestinal issue but are not specific to cancer.
Correct Answer is C
Explanation
A. Gradual decreases in rate and depth are typically seen in other respiratory conditions, not Cheyne- Stokes breathing.
B. Wheezing is not associated with Cheyne-Stokes breathing but may be related to airway obstructions or lung conditions.
C. Cheyne-Stokes breathing is characterized by a pattern of deep, rapid breathing followed by a period of apnea, commonly seen in terminally ill patients.
D. Quick shallow respirations with long periods of apnea are not characteristic of Cheyne-Stokes breathing.
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