The nurse is teaching the community about blood pressure. What blood pressure finding by the nurse indicates that no changes in therapy are needed for a client with newly diagnosed hypertension?

128/76 mm Hg

128/92 mm Hg

98/56 mm Hg

142/78 mm Hg

Answer and Explanation

The Correct Answer is A

Hypertension is typically diagnosed when a person's blood pressure consistently exceeds 130/80 mm Hg on multiple occasions. However, the specific target blood pressure for treatment may vary based on individual factors and the presence of other comorbidities.

Among the options provided, a blood pressure reading of 128/76 mm Hg is within the target range for many individuals with hypertension. The systolic pressure (128 mm Hg) is below the threshold of 130 mm Hg, and the diastolic pressure (76 mm Hg) is below the threshold of 80 mm Hg.

The other blood pressure readings would warrant further evaluation or possible changes in therapy:

128/92 mm Hg: The diastolic pressure (92 mm Hg) is above the threshold of 80 mm Hg, indicating uncontrolled hypertension.

98/56 mm Hg: This blood pressure reading is below the threshold for hypertension, but it is considered low and may require further assessment to determine if it is normal for the individual or if it indicates hypotension.

142/78 mm Hg: While the systolic pressure (142 mm Hg) is slightly above the threshold of 130 mm Hg, it may not necessarily require immediate changes in therapy. However, it should be closely monitored to ensure blood pressure control.

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Correct Answer is C

Explanation

The most important finding to report to the health care provider would be the serum potassium level of 3.0 mEq. This is an extremely low potassium level (normal range is typically 3.5-5.0 mEq/L), which can indicate a potentially life-threatening condition called hypokalemia. Furosemide (Lasix) is a diuretic medication that can cause potassium loss in the urine, and a low potassium level can lead to serious cardiac and muscle abnormalities. It is crucial to report this finding promptly to the health care provider for appropriate intervention and monitoring.

Blood glucose level of 175 mg/dL: While an elevated blood glucose level can be a concern, especially for individuals with diabetes, it is not the most critical finding in this situation. The client's primary concern is hypertension, and the administration of IV furosemide is aimed at managing blood pressure. The elevated blood glucose level should still be addressed and monitored, but it is not as urgent as the low potassium level.

Orthostatic systolic BP decrease of 12 mm Hg: Orthostatic hypotension refers to a significant decrease in blood pressure upon standing up. While it is important to assess and manage orthostatic changes, a decrease of 12 mm Hg in systolic blood pressure alone may not be considered clinically significant. It could be a normal response for some individuals. However, if the client experiences symptoms such as dizziness or lightheadedness upon standing, further evaluation may be necessary. Nonetheless, it is not as urgent as the low potassium level.

Current blood pressure reading of 166/94 mm Hg: While this blood pressure reading indicates hypertension, it is not the most critical finding to report in this situation. The nurse is preparing to administer furosemide (Lasix), which is a medication commonly used to treat hypertension. It is expected that the blood pressure will be high before administering the medication. The goal is to monitor the blood pressure after the administration to assess the effectiveness of the medication.

A. Obtain consent for transesophageal echocardiogram (TEE) B. Obtain consent for a STAT defibrillation C. Obtain consent for cardioversion. D. Hold digoxin 48 hours prior to cardioversion.

Correct Answer is B

Explanation

Defibrillation is not the first-line treatment for atrial fibrillation. It is used to treat life-threatening cardiac arrhythmias such as ventricular fibrillation or pulseless ventricular tachycardia. Atrial fibrillation, on the other hand, is a rapid and irregular atrial rhythm, and defibrillation is not indicated for its treatment.

Obtain consent for transesophageal echocardiogram (TEE): This is an appropriate action for a client with atrial fibrillation. A TEE is often performed to assess the structure and function of the heart in cases of atrial fibrillation, especially when considering cardioversion or other interventions.

Obtain consent for cardioversion: Cardioversion is a common treatment option for atrial fibrillation, especially when the client is unstable or experiencing symptoms. It involves restoring a normal heart rhythm through the use of electrical shocks or medications. It is important to obtain informed consent before performing cardioversion, but this does not necessarily require questioning.

Hold digoxin 48 hours prior to cardioversion: Digoxin is commonly held before cardioversion because it can increase the risk of certain arrhythmias during the procedure. This is a standard precaution to minimize potential adverse effects. Therefore, the nurse does not need to question this action, as it aligns with established guidelines.

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The nurse is teaching the community about blood pressure. What blood pressure finding by the nurse indicates that no changes in therapy are needed for a client with newly diagnosed hypertension?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to administer IV furosemide (Lasix) to a client with hypertension. What is the most important finding to report to the health care provider?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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