The nurse is caring for a patient with the following vital signs:
- Temperature: 98.9° F
- Pulse: 94
- Respirations: 20
- Blood pressure: 144/94
- Pulse oximetry: 94%
What is the priority action of the nurse?
Document the findings in the patient's medical record.
Apply a cool washcloth to the patient's forehead.
Administer oxygen at 2 U/minute via nasal cannula.
Ask the patient about his usual blood pressure results.
The Correct Answer is D
A. Document the findings in the patient's medical record. While documentation is important, further assessment is needed before determining if the blood pressure is abnormal for this patient.
B. Apply a cool washcloth to the patient's forehead. The patient’s temperature is normal (98.9°F), so there is no need for cooling measures.
C. Administer oxygen at 2 L/minute via nasal cannula. The pulse oximetry is 94%, which is adequate for most patients. Oxygen is not needed unless the patient shows signs of respiratory distress.
D. Ask the patient about his usual blood pressure results. The blood pressure (144/94 mmHg) is elevated, but before determining if intervention is needed, the nurse should ask if this is typical for the patient or if it is an isolated finding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Perception occurs when the brain interprets pain signals and recognizes them as pain. This step happens after the nerve impulses have been transmitted to the brain.
B. Transduction is the first step in the pain process, where painful stimuli (such as cutting a finger) activate nociceptors, converting the stimulus into an electrical signal.
C. Modulation involves the body’s response to pain signals, where descending nerve pathways release substances like endorphins to inhibit pain transmission. This occurs later in the pain process.
D. Transmission is the process of pain signals traveling from the site of injury to the spinal cord and brain via afferent nerve fibers. This step occurs after transduction and allows pain signals to reach the central nervous system.
Correct Answer is A
Explanation
A. Carotid. The carotid arteries supply blood to the brain, and compressing both simultaneously can reduce cerebral blood flow, potentially causing dizziness, syncope, or loss of consciousness. Therefore, carotid pulses should be assessed one at a time.
B. Radial. The radial pulse can be safely assessed bilaterally at the same time since it does not affect central circulation or brain perfusion.
C. Brachial. The brachial pulse can also be assessed bilaterally without risk, as it does not impact blood flow to critical organs like the brain.
D. Femoral. The femoral pulse can be checked simultaneously on both sides to assess circulation and perfusion, especially in cases of suspected arterial insufficiency.
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