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A group of student nurses are practicing taking blood pressures. A 56-year-old male student has a blood pressure reading of 146/96 mm Hg. Upon hearing the reading, he exclaims, “My pressure has never been this high. Do you think my doctor will prescribe medication to reduce it?” Which of the following responses by the nursing instructor would be best?

“A single elevated blood pressure does not confirm hypertension. A diagnosis of hypertension requires two or more elevated readings taken by your physician before a diagnosis can be made.”

“We will need to reevaluate your blood pressure because your age places you at high risk for hypertension.”

“Hypertension is prevalent among men: it is fortunate we caught this during your routine examination.”

“You have no need to worry. Your pressure is probably elevated because you are being tested.”

Answer and Explanation

The Correct Answer is A

A. "A single elevated blood pressure does not confirm hypertension. A diagnosis of hypertension requires two or more elevated readings taken by your physician before a diagnosis can be made."

This response emphasizes the need for multiple elevated readings for a diagnosis of hypertension. It educates the individual about the diagnostic criteria and encourages them to seek further evaluation from their physician.

B. "We will need to reevaluate your blood pressure because your age places you at high risk for hypertension."

This response might be seen as implying that age alone is a significant factor in determining hypertension, which may not be accurate. While age is a risk factor, the emphasis should be on the need for multiple readings and a physician's evaluation rather than attributing it solely to age.

C. "Hypertension is prevalent among men: it is fortunate we caught this during your routine examination."

This response suggests that the elevated blood pressure is automatically assumed to be hypertension based on gender. It is important to avoid making assumptions and instead focus on the need for proper evaluation and multiple readings for a hypertension diagnosis.

D. "You have no need to worry. Your pressure is probably elevated because you are being tested."

This response dismisses the individual's concerns and attributes the elevated blood pressure solely to the testing situation. While stress or anxiety can influence blood pressure readings, it's essential to address the need for further evaluation and not completely disregard the possibility of hypertension.

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Free Nursing Study Resources

Correct Answer is ["0.75"]

Explanation

The nurse needs to calculate the correct dose of atropine for a client who has a prescription for 0.3 mg IV stat. The nurse knows that atropine is a medication that blocks the effects of the parasympathetic nervous system and is used to treat bradycardia, heart block, and some types of poisoning.

To find out how many milliliters of atropine the nurse will administer, the nurse can use the formula:

Dose ordered / Dose available = Volume to administer

Plugging in the values, the nurse gets:

0.3 mg / 0.4 mg per mL = 0.75 mL

Therefore, the nurse will administer 0.75 mL of atropine to the client IV stat.

A. Lie in a low Fowler’s or supine position B. Increase oral fluids unless contraindicated C. Increase activity D. Call the nurse for oral suctioning as needed

Correct Answer is D

Explanation

A. Lie in a low Fowler’s or supine position:

Lying in a low Fowler's or supine position may worsen respiratory distress and compromise oxygenation. It can reduce lung expansion and increase the work of breathing, especially in patients with pneumonia. This is not a recommended position for individuals with respiratory issues.

B. Increase oral fluids unless contraindicated:

Increasing oral fluids is generally a good practice, especially in respiratory conditions like pneumonia. It helps thin respiratory secretions, making them easier to clear. However, this alone may not address copious tracheobronchial secretions. Suctioning may be needed to effectively remove excess secretions.

C. Increase activity:

Increasing activity may be beneficial for some patients, but it might exacerbate respiratory distress in others, especially if they are already experiencing increased work of breathing. The appropriateness of increasing activity depends on the specific condition and the patient's overall stability.

D. Call the nurse for oral suctioning as needed:

This is the most appropriate choice. If the client is experiencing increased work of breathing due to copious tracheobronchial secretions, calling the nurse for oral suctioning is an intervention aimed at maintaining a clear airway and alleviating respiratory distress. Regular suctioning may be necessary to assist the client in managing secretions effectively.

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Naxlex Comprehensive Predictor Exams

A client is ordered to receive atropine 0.3 mg IV stat. Atropine 0.4 mg per mL is available. How many milliliters will the nurse administer?

Correct Answer is ["0.75"]

Explanation

A critical-care nurse is caring for a client diagnosed with pneumonia as a surgical complication. The nurse’s assessment reveals that the client has an increased work of breathing due to copious tracheobronchial secretions. What should the nurse encourage the patient to do?

Correct Answer is D

Explanation

The nurse is teaching a client about some of the health consequences of uncontrolled hypertension. What health problems should the nurse describe. (SELECT ALL THAT APPLY)

An emergency department nurse is assessing an adult woman for a suspected myocardial infarction (MI). When planning the assessment, the nurse should be aware that female patients may have which of the following symptoms for an MI? (SELECT ALL THAT APPLY)

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The nurse is taking the history of a client with occupational lung disease (silicosis). The nurse should assess whether the client wears which item during periods of exposure to silica particles?

What is the best indication if the client with congestive heart failure is holding excess fluid?

The nurse is caring for a patient who has decreased mobility. Which intervention is a simple and cost-effective method for reducing the risks of stasis of pulmonary secretions and decreased chest wall expansion?

The nurse is taking health history for a client who reports pain in his lower left leg and foot when walking. The pain is relieved with rest, and the nurse observes the left leg is hairless and slightly edematous. The nurse recognizes this as which medical diagnosis or health problem?

A client is being admitted to the medical unit to rule out cardiac issues related to valve malfunction. Which question should the nurse ask the client during the admission interview to support this diagnosis?