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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Dyspnea on exertion: Anemia from blood loss reduces oxygen-carrying capacity, leading to symptoms like fatigue and dyspnea on exertion. The patient's low SpO₂, tachycardia, and increased respiratory rate are consistent with this finding.

B. Respiratory depression: Respiratory depression is typically associated with narcotics or other depressants, not anemia due to blood loss. The increased respiratory rate suggests a compensatory mechanism for decreased oxygenation, not depression.

C. Intense abdominal pain: While abdominal pain could be present in some conditions, it is not a direct symptom of anemia due to surgical blood loss and decreased perfusion.

D. Bradycardia: Anemia usually causes tachycardia (increased heart rate) as the body compensates for the decreased oxygenation, not bradycardia (slow heart rate). Therefore, bradycardia is unlikely in this case.

A. Check pedal pulses every 15 min. B. Keep the client in high-Fowler's position for 6 hr. C. Remind the client not to turn from side to side. D. Perform passive range-of-motion for the affected extremity.

Correct Answer is A

Explanation

A. Check pedal pulses every 15 min. Checking pedal pulses every 15 minutes is essential to monitor for adequate blood flow to the extremity and to detect any signs of arterial obstruction or complications at the catheter insertion site.

B. Keep the client in high-Fowler's position for 6 hr. The client should remain flat or in a low-Fowler's position to reduce the risk of bleeding at the femoral artery access site. High-Fowler's position is contraindicated.

C. Remind the client not to turn from side to side. Clients may be allowed to turn gently, but they should avoid putting pressure on the insertion site. Complete immobility is unnecessary.

D. Perform passive range-of-motion for the affected extremity. Passive range of motion is not appropriate in the immediate post-procedure period, as the extremity should remain still to prevent bleeding.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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