A nurse on a medical-surgical unit is collecting data from a client who is postoperative following abdominal surgery.
The client’s BP was 126/72 mm Hg 15 min ago. The nurse now finds that the client’s BP is 176/96 mm Hg. Which of the following actions should the nurse take?

Deflate the cuff faster when repeating the BP measurement.

Request a prescription for an antihypertensive medication.

Use a narrower cuff to repeat the BP measurement.

Measure the client’s BP in the other arm.

Answer and Explanation

The Correct Answer is D

It's common practice to check blood pressure in both arms when there is a significant discrepancy in blood pressure readings between the arms. This discrepancy could be due to factors like arterial blockages or other conditions. By measuring the blood pressure in the other arm, the nurse can confirm whether the high blood pressure is consistent on both sides or if there was an issue with the initial measurement. This step helps provide a more accurate assessment of the client's blood pressure.

- The other options are not appropriate at this stage:

Deflating the cuff faster may not resolve the issue and could lead to inaccurate measurements.

Requesting a prescription for an antihypertensive medication should only be done after confirming the blood pressure is consistently elevated and under the direction of a healthcare provider.

Using a narrower cuff is not indicated in this situation. It's more important to assess the other arm's blood pressure to identify any discrepancies.

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Correct Answer is ["A","B","C","D","E"]

No explanation

A. “Why do you think they don’t know what’s happening?” B. “It sounds like you have given up and want to stay mad at your family.”. C. “I think you and I need to talk about your anger with your family.” D. “You are feeling angry that your family continues to wish for a cure?”

Correct Answer is D

Explanation

The correct answer is choice D. “You are feeling angry that your family continues to wish for a cure?”.

This response reflects the client’s feelings and encourages further communication.

It also shows empathy and respect for the client’s situation.

Choice A is wrong because it implies that the client is responsible for their family’s lack of understanding.

It may also make the client feel defensive or guilty.

Choice B is wrong because it is judgmental and dismissive of the client’s feelings.

It may also discourage the client from expressing their emotions.

Choice C is wrong because it focuses on the nurse’s needs rather than the client’s.

It may also sound intrusive or presumptuous to the client.

Hospice care is for people who are in the final stages of an incurable illness and want to focus on comfort and quality of life rather than curative treatments.

Hospice care teams provide physical, emotional, social, and spiritual support to clients and their families.

Hospice care can be provided at home, in a hospital, in a nursing home, or in a specialized hospice center.

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A nurse on a medical-surgical unit is collecting data from a client who is postoperative following abdominal surgery. The client’s BP was 126/72 mm Hg 15 min ago. The nurse now finds that the client’s BP is 176/96 mm Hg. Which of the following actions should the nurse take?

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Correct Answer is D

Explanation

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A nurse on a medical-surgical unit is collecting data from a client who is postoperative following abdominal surgery.
The client’s BP was 126/72 mm Hg 15 min ago. The nurse now finds that the client’s BP is 176/96 mm Hg. Which of the following actions should the nurse take?