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
Explanation
A. Gathering information from a family member can help obtain a more accurate history, especially when the patient has difficulty recalling specific details due to age-related memory changes.
B. Omitting the interview would lead to incomplete information and potentially delay appropriate care.
C. Repeating the questions may be helpful but may not always yield reliable data if the patient struggles to remember key details.
D. While forgetfulness can be normal with aging, healthcare providers need to ensure accurate information is collected to provide optimal care.
Correct Answer is C
Explanation
A. The area directly below the sternum is not the location for the apical pulse.
B. The third intercostal space is too high for the apical pulse, which is best heard at the fifth intercostal space.
C. The left midclavicular line at the fifth intercostal space is the proper location for auscultating the apical pulse.
D. Placing the stethoscope above the left nipple does not ensure accurate assessment of the apical pulse.
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