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. Elevate the head of the bed 45 degrees. B. Limit fluid intake for 4 hr after the procedure. C. Have the client rest in bed for 2 hr. D. Insert an indwelling urinary catheter 1 hr post procedure.

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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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

A nurse is assisting with the plan of care for a client immediately following a cardiac catheterization with coronary angiography. An arterial closure device was used to close the access site. Which of the following interventions should the nurse recommend?

Correct Answer is C

Explanation

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