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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D. This type of device is useful for a client who cannot assist.
A mechanical lift is used to transfer residents who cannot support their own weight.
It does not require the client to use upper body strength, as choice A suggests.
The lower end of the sling should go under the client’s thighs, not below the calves, as choice B states.
The sides of the sling are not for the client to hold on to, but for the caregiver to attach to the hooks on the lift, as choice C implies.
Therefore, choices A, B and C are wrong because they do not reflect the proper use of a mechanical lift.
Correct Answer is C
Explanation
The correct answer is choice C. Use a filter needle to aspirate the medication.
This is because a filter needle can prevent glass particles from being drawn into the syringe when aspirating medication from an ampule.
Glass particles can cause harm to the patient if injected.
Choice A is wrong because cleansing the tip of the ampule with an alcohol swab after opening is not necessary and may contaminate the medication.
Choice B is wrong because adding 0.5 mL of diluent to the medication may alter the concentration and dosage of the medication.
Choice D is wrong because injecting air into the ampule prior to drawing the medication into a syringe is not required and may create pressure that can cause the ampule to break.
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