A patient’s blood pressure suddenly drops from 132/82 to 104/52. The nurse notes that the patient’s skin is pale and the patient appears ready to faint. What is the priority action of the nurse?
Report the findings to the health care provider immediately.
Check the patient’s apical rate to check for a pulse deficit.
Immediately check the patient for orthostatic hypotension.
Elevate the head of the patient’s bed to at least 45 degrees.
The Correct Answer is C
Choice A reason: This is incorrect. Reporting the findings to the health care provider immediately is an important step, but not the priority action of the nurse. The nurse should first assess the patient for orthostatic hypotension, which is a common cause of sudden blood pressure drop.
Choice B reason: This is incorrect. Checking the patient’s apical rate to check for a pulse deficit is a relevant step, but not the priority action of the nurse. A pulse deficit is the difference between the apical and radial pulse rates. The nurse should first check the patient for orthostatic hypotension, which is a condition where the blood pressure drops when the patient changes position, causing dizziness and fainting.
Choice C reason: This is correct. Immediately checking the patient for orthostatic hypotension is the priority action of the nurse. Orthostatic hypotension is a condition where the blood pressure drops when the patient changes position, causing dizziness and fainting. It can be caused by dehydration, medications, blood loss, or autonomic nervous system disorders. The nurse should measure the patient’s blood pressure and heart rate while lying down, sitting, and standing, and observe for any signs of hypoperfusion, such as pallor, sweating, or confusion.
Choice D reason: This is incorrect. Elevating the head of the patient’s bed to at least 45 degrees is a helpful step, but not the priority action of the nurse. Elevating the head of the bed can improve the patient’s breathing and reduce the risk of aspiration, but it can also worsen the orthostatic hypotension by lowering the blood pressure further. The nurse should first check the patient for orthostatic hypotension and then adjust the bed position accordingly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
Choice A reason: This is a correct choice because switching the patient’s injected pain medication to oral tablets before discharge is an example of an independent nursing intervention. An independent nursing intervention is an action that the nurse can perform based on their own knowledge, skills, and judgment without a physician's order. The nurse can decide when to switch the route of administration of the pain medication based on the patient's condition, preference, and readiness for discharge.
Choice B reason: This is a correct choice because elevating the head of the patient’s bed to facilitate use of the incentive spirometer is an example of an independent nursing intervention. An independent nursing intervention is an action that the nurse can perform based on their own knowledge, skills, and judgment without a physician's order. The nurse can adjust the position of the patient's bed to promote lung expansion and prevent atelectasis, which are common postoperative complications.
Choice C reason: This is an incorrect choice because administering intravenous fluids when the patient is unable to eat or drink is an example of a dependent nursing intervention. A dependent nursing intervention is an action that the nurse can perform only with a physician's order. The nurse cannot give any intravenous fluids to the patient without a prescription.
Choice D reason: This is a correct choice because advancing a patient’s diet from clear liquids to solid foods after surgery is an example of an independent nursing intervention. An independent nursing intervention is an action that the nurse can perform based on their own knowledge, skills, and judgment without a physician's order. The nurse can progress the patient's diet based on the patient's tolerance, appetite, and bowel function.
Choice E reason: This is a correct choice because teaching patients with heart failure how to do accurate daily weights is an example of an independent nursing intervention. An independent nursing intervention is an action that the nurse can perform based on their own knowledge, skills, and judgment without a physician's order. The nurse can educate the patient about the importance of monitoring their weight and fluid status and document the teaching.
Correct Answer is D
Explanation
Choice A reason: This is incorrect. Wiping up the liquid with paper towels and gloves can spread the mercury droplets and increase the risk of exposure. Mercury can also penetrate through nitrile gloves and cause skin irritation.
Choice B reason: This is incorrect. Disinfecting the area with chlorine bleach can create toxic vapours that can harm the respiratory system. Chlorine bleach is not effective in removing mercury from the surface.
Choice C reason: This is incorrect. Contacting the housekeeping staff to mop up the liquid can delay the proper clean-up and disposal of mercury. Mopping can also disperse the mercury droplets and contaminate the mop and the water.
Choice D reason: This is correct. Consulting the agency’s materials safety data sheets (MSDS) is the priority action of the nurse. MSDS provide information on the hazards, precautions, and procedures for handling and disposing of mercury. The nurse should follow the MSDS guidelines and use the appropriate equipment and methods to clean up the spill.
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