A client has a prescription for vital sign measurement every four hours. The nurse observes that the client's blood pressure has increased from 140/60 mm Hg at noon to 180/90 mm Hg four hours later. Which action should the nurse implement?

Plan to measure the blood pressure in four hours as prescribed.

Repeat the client's blood pressure measurement in fifteen minutes.

Obtain an automatic blood pressure machine for hourly readings.

Reassess the blood pressure if the client reports other symptoms.

Answer and Explanation

The Correct Answer is B

A. Plan to measure the blood pressure in four hours as prescribed. Waiting for another four hours may not be appropriate given the significant increase in blood pressure. Immediate action is needed to address the elevated reading.

B. Repeat the client’s blood pressure measurement in fifteen minutes. This is the most appropriate action. When a client’s blood pressure is significantly elevated, it’s essential to recheck it promptly to confirm accuracy and assess for any changes. Fifteen minutes allows enough time for a follow-up measurement without unnecessary delay.

C. Obtain an automatic blood pressure machine for hourly readings. While continuous monitoring is valuable in some situations, it’s not necessary for routine blood pressure assessments. Hourly readings would be excessive and may not provide additional useful information.

D. Reassess the blood pressure if the client reports other symptoms. While assessing other symptoms is essential, waiting for symptoms to occur before reassessing blood pressure is not the best approach. Immediate follow-up is warranted based on the elevated reading alone

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. A bubbling sound heard during inspiration and expiration in the central airways: This description is accurate. Crackles (also called rales) are often heard in conditions like pulmonary edema or pneumonia.

B. A crowing noise heard during inspiration over the trachea: This description refers to stridor, not crackles. Stridor occurs due to upper airway obstruction.

C. Popping, non-musical sounds heard in the lung bases, usually during inspiration: This description is accurate for crackles. They occur due to fluid or secretions in the alveoli.

D. Superficial squeaking or grating sounds heard during inspiration and expiration: This description refers to wheezes, not crackles. Wheezes are associated with narrowed airways.

A. Conduct an assessment of functional capacity and environmental hazards. B. Distinguish between symptoms caused by disease and those due to aging. C. Obtain a medication history including prescription and non-prescription drugs. D. Emphasize the need to place advance directives in the medical record.

Correct Answer is C

Explanation

A. Functional capacity: While important for older adults, it's not the most pressing concern during this routine follow-up exam.

B. Distinguishing symptoms: This is an ongoing process, but not the most critical element for this visit.

C. Obtain a medication history including prescription and non-prescription drugs. Cataract surgery often involves medication changes or new medications to prevent infection or manage other post-operative needs. An updated medication history helps identify potential interactions or side effects.

D. Advance directives: While important for all adults, it might not be the most urgent topic for this specific follow-up exam focused on managing existing conditions and potential post-surgical medications.

View Question and Answer

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

A client has a prescription for vital sign measurement every four hours. The nurse observes that the client's blood pressure has increased from 140/60 mm Hg at noon to 180/90 mm Hg four hours later. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse hears crackles when auscultating a client's lung sounds. Which is an accurate description of the sound of crackles?

Correct Answer is C

Explanation

Correct Answer is C

Explanation

Gestational Ultrasound. In preparing the client for the procedure, the nurse should explain that the primary reason for conducting the ultrasound is to obtain which information?

While performing a physical assessment, the nurse is unable to palpate the client's pedal pulses. Which action should the nurse take?

An older Native-American client with hypertension presents to an outpatient clinic for follow-up evaluation after initiation of treatment with oral antihypertensive medications. Report of which client behavior requires additional assessment by the nurse?

When-obtaining an adolescent's health history, which intervention is most important of the nurse to implement?

The nurse completes percussion of the abdomen on an adult client. Which finding is considered normal?

The nurse is assessing a 38-week gestation newborn infant immediately following a vaginal birth. Which assessment finding best indicates that the infant is transitioning well to extrauterine life?

In assessing a male client's level of consciousness, the nurse determines that the client does not open his eyes spontaneously. Which should the nurse do next?