A nurse is collecting a blood pressure (BP) reading from a client who is sitting in a chair. The nurse determines that the client's BP is 158/96 mm Hg. Which of the following actions should the nurse take?
Request that another nurse check the client's BP in 30 min.
Reposition the client supine and recheck her BP.
Recheck the client's BP in her other arm for comparison.
Ensure that the width of the BP cuff is 50% of the client's upper arm circumference
The Correct Answer is C
A. Request that another nurse check the client's BP in 30 min:
Waiting for 30 minutes to have another nurse check the blood pressure may not be the most immediate and effective action. If there are concerns about the accuracy of the reading, rechecking the BP in the other arm promptly is a more appropriate and efficient approach.
B. Reposition the client supine and recheck her BP:
Repositioning the client supine is not necessary in this context. Blood pressure can be accurately measured while the client is sitting. Changing the position might not provide relevant information about the accuracy of the blood pressure reading.
C. Recheck the client's BP in her other arm for comparison:
This is the appropriate action. Checking the blood pressure in the other arm can help determine if there is a significant difference between the arms. A significant difference could indicate arterial disease or other issues. It's essential to confirm the accuracy of the blood pressure measurement.
D. Ensure that the width of the BP cuff is 50% of the client's upper arm circumference:
While ensuring the appropriate size of the BP cuff is essential for accurate readings, this option is not directly addressing the current situation of an elevated blood pressure reading. Checking the other arm for comparison is more relevant to assess the accuracy of the measurement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "I will walk three times per week."
Weight-bearing exercises like walking help strengthen bones and reduce the risk of osteoporosis. Regular physical activity is a key component in maintaining bone health.
B. "I will take 250 milligrams of calcium once per day."
This amount of calcium is insufficient. The recommended daily intake for older adults is typically around 1,000 to 1,200 milligrams of calcium per day, divided into doses for better absorption.
C. "I will decrease my intake of dairy products."
Dairy products are rich sources of calcium and are beneficial for bone health. Decreasing their intake would not be advisable for reducing the risk of osteoporosis.
D. "I will avoid exposure to the sun."
Sun exposure helps the body produce vitamin D, which is essential for calcium absorption and bone health. Avoiding sun exposure could lead to a deficiency in vitamin D, increasing the risk of osteoporosis.
Correct Answer is ["A","B","C","F"]
Explanation
Correct responses
A. Lactose intolerant: Lactose intolerance can lead to lower dairy intake, which may reduce calcium intake, increasing the risk of osteoporosis.
B. Alcohol use: Excessive alcohol consumption can interfere with calcium absorption and bone health, increasing the risk of osteoporosis.
C. Smoking history: Smoking is associated with decreased bone density and increased risk of osteoporosis due to its negative effects on bone metabolism.
F. Vitamin D level: The client's vitamin D levels are below the recommended range. Vitamin D is crucial for calcium absorption and bone health, so insufficient levels can increase the risk of osteoporosis.
The other factors are less directly related to osteoporosis risk in this client:
D. Phosphorous level: The phosphorous level is within the normal range and is not directly linked to osteoporosis risk.
E. Activity level: The activity level is not provided in the information; however, physical activity is generally important for bone health. If the client is sedentary, it could be a risk factor, but it's not specified here.
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