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 D
Explanation
A. Temperature monitoring is important but not a top priority when a patient is receiving opiates unless there is suspicion of infection.
B. Pulse monitoring is also important but does not immediately indicate issues with opiate use.
C. Blood pressure is influenced by opiate use, but the primary concern is respiratory function due to the risk of respiratory depression.
D. Respirations should be closely monitored because opiates can significantly depress the respiratory system, leading to hypoventilation or respiratory arrest, which is the most critical risk.
Correct Answer is D
Explanation
A. Rinsing the thermometer with water is not necessary to ensure an accurate reading. The thermometer should be cleaned after use but rinsing with water does not directly ensure accuracy.
B. Using a dry cotton ball to dry the thermometer is unnecessary and could leave fibers on the device that may interfere with reading accuracy.
C. Wiping the thermometer with alcohol helps sanitize it but does not directly influence the accuracy of the reading.
D. Shaking down the galinstan alloy to below normal is necessary to reset the thermometer before use, ensuring that the mercury level is accurate when taking a new temperature.
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