During a physical assessment, the nurse observes that a client's blood pressure is 160/100 mmHg. What action should the nurse take?

Recheck the blood pressure using a different cuff size.

Document the blood pressure findings as the only action required.

Administer an antihypertensive medication immediately.

Notify the healthcare provider of the elevated blood pressure.

Answer and Explanation

The Correct Answer is D

Answer: d. Notify the healthcare provider of the elevated blood pressure.

Explanation: A blood pressure reading of 160/100 mmHg indicates hypertension and requires further evaluation by the healthcare provider to determine appropriate management.

a. Rechecking the blood pressure with a different cuff size may be appropriate if the initial reading was inaccurate, but it does not address the elevated blood pressure result.

b. Documenting the finding is important, but further action is required for elevated blood pressure.

c. Administering antihypertensive medication without consulting the provider is not appropriate; medication decisions should be made by the healthcare provider.

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Correct Answer is B

Explanation

indicate poor sensor placement or a faulty pulse oximeter. The nurse should reapply the pulse oximeter on a different finger to obtain an accurate reading.

a. An irregular waveform is not a normal variation and should be investigated further.

c. Assessing the client for signs of respiratory distress is important but may not directly address the irregular waveform.

d. Notifying the healthcare provider may be necessary if the issue persists after reapplying the pulse oximeter.

A. Inflate the cuff to 20 mmHg above the estimated systolic pressure. B. Deflate the cuff at a rate of 10-20 mmHg per second. C. Place the bell of the stethoscope over the brachial artery. D. Palpate the radial artery while auscultating for Korotkoff sounds.

Correct Answer is C

Explanation

Answer: c. Place the bell of the stethoscope over the brachial artery.

Explanation: To obtain an accurate blood pressure reading, the nurse should place the bell of the stethoscope over the brachial artery, which is located in the antecubital fossa.

a. Inflating the cuff to 20 mmHg above the estimated systolic pressure may be appropriate for initial inflation, but the cuff should be inflated further until the radial pulse disappears, and then slowly deflated to obtain accurate readings.

b. Deflating the cuff at a rate of 2-3 mmHg per second is recommended to obtain accurate blood pressure readings.

d. Palpating the radial artery while auscultating for Korotkoff sounds is not necessary for accurate blood pressure measurement and may interfere with accurate assessment.

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During a physical assessment, the nurse observes that a client's blood pressure is 160/100 mmHg. What action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client's pulse oximetry reading and notices that the waveform is irregular and inconsistent. What action should the nurse take?

Correct Answer is B

Explanation

A nurse is assessing a client's blood pressure using a manual sphygmomanometer and a stethoscope. What action should the nurse take to obtain an accurate blood pressure reading?

Correct Answer is C

Explanation

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