A nurse is reinforcing teaching with a client who has a family history of hypertension. The nurse should inform the client that his blood pressure reading of 124/74 mm Hg places him in which of the following categories or stages?
Hypertension stage 2
Elevated or Prehypertension
Hypertension stage 1
Within the expected reference range
The Correct Answer is B
A. Hypertension stage 2: Hypertension stage 2 is defined as a systolic blood pressure ≥140 mm Hg or diastolic ≥90 mm Hg. The client’s reading of 124/74 mm Hg does not fall into this category.
B. Elevated or Prehypertension: A systolic blood pressure between 120-129 mm Hg and a diastolic <80 mm Hg is classified as elevated or prehypertension. The client’s systolic BP of 124 mm Hg places him in this category.
C. Hypertension stage 1: Hypertension stage 1 is defined as a systolic BP between 130-139 mm Hg or diastolic BP between 80-89 mm Hg. The client’s BP of 124/74 mm Hg does not meet this criterion.
D. Within the expected reference range: The normal range for blood pressure is less than 120/80 mm Hg. The client’s BP of 124/74 mm Hg is slightly elevated and does not fall within the expected reference range.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Count the apical pulsations for a full minute. The apical pulse should be counted for a full minute to ensure accuracy, especially in clients taking cardiovascular medications, as these may affect heart rhythm and rate.
B. Place the stethoscope just under the mid-clavicular area of the left chest. The apical pulse is typically located at the fifth intercostal space at the midclavicular line, not directly under the clavicle.
C. Press the stethoscope firmly against the client's skin. While the stethoscope needs to be in full contact with the skin, excessive pressure is not necessary and may distort the sound.
D. Check the apical pulse with a Doppler device. A Doppler is typically used when the pulse is difficult to palpate or auscultate, not as a first-line method for checking the apical pulse.
Correct Answer is C
Explanation
A. Elevate the head of the bed 45 degrees. The head of the bed should not be elevated this high, as this can increase pressure on the arterial access site, risking bleeding or disruption of the closure device.
B. Limit fluid intake for 4 hr after the procedure. Fluids should actually be encouraged to help flush out contrast dye used during the procedure and to maintain hydration. Limiting fluids could increase the risk of renal complications.
C. Have the client rest in bed for 2 hr. Bed rest is typically required after cardiac catheterization, especially with the use of an arterial closure device. Two hours is a reasonable time for initial bed rest following the procedure.
D. Insert an indwelling urinary catheter 1 hr post procedure. A urinary catheter is not routinely required after a cardiac catheterization unless there are specific medical indications.
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