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
Correct Answer is A
Explanation
The correct answer is choice A. Evaluate the client’s concerns and communicate them to the provider.
This is because the nurse’s role as a patient advocate is to speak, act or behave in a way that benefits their patient, who may not be able to support or promote their own needs or interests.
The nurse should provide patients with information regarding their diagnoses, prognoses, treatments, and alternatives, and serve as a patient’s voice when necessary.
Choice B is wrong because contacting the unit’s social worker to report the client’s refusal is not an appropriate action for the nurse to take as a patient advocate.
The nurse should respect the patient’s autonomy and right to refuse treatment, and not involve other professionals without the patient’s consent.
Choice C is wrong because asking the client’s partner to find out why the client has refused the procedure is not an appropriate action for the nurse to take as a patient advocate.
The nurse should communicate directly with the patient and not rely on third parties to obtain information or influence the patient’s decision.
Choice D is wrong because explaining the necessity of the procedure to the client is not an appropriate action for the nurse to take as a patient advocate.
The nurse should not impose their own values or opinions on the patient, but rather provide unbiased and factual information and support the patient’s informed choice.
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