The nurse measures the client’s blood pressure (BP) and notes that it is significantly higher than the previous reading. Which should the nurse do next? (Select all that apply)

Immediately take 2 more readings on the same arm.

Assign the unlicensed assistive personnel (UAP) to recheck the BP in an hour.

Retake the client’s blood pressure in the opposite arm.

Ask another nurse to assist in assessing for an apical-radial pulse deficit.

Determine the client’s activity and feelings prior to the BP measurement.

Answer and Explanation

Correct Answer : A,C,E

Choice A reason: Taking two more readings confirms elevated BP, as a single reading may reflect technique errors or transient factors like pain, which increase sympathetic activity and vasoconstriction. Multiple readings ensure accuracy, critical for diagnosing hypertension and guiding intervention to prevent cardiovascular complications like stroke.

Choice B reason: Assigning a UAP to recheck BP in an hour delays assessment of potentially dangerous hypertension, which risks acute complications like myocardial ischemia. Immediate confirmation is needed, as elevated BP from norepinephrine release increases vascular resistance, making delayed rechecking inappropriate for urgent evaluation.

Choice C reason: Retaking BP in the opposite arm verifies accuracy, as differences may indicate arterial occlusion. Elevated BP increases catecholamine-driven vascular resistance. Measuring both arms rules out localized issues, ensuring reliable data to guide management of hypertension, critical to prevent end-organ damage like renal failure.

Choice D reason: Assessing apical-radial pulse deficit is relevant for atrial fibrillation, not directly for elevated BP. Hypertension results from increased vascular resistance, not pulse discrepancies. Confirming BP and assessing context are more immediate to determine urgency, making this less relevant than verifying readings or identifying triggers.

Choice E reason: Determining activity and feelings identifies transient BP elevation causes, like stress or exercise, which raise norepinephrine, increasing heart rate and vascular tone. This contextualizes the reading, differentiating situational from chronic hypertension, ensuring appropriate intervention to manage cardiovascular risk and guide further assessment.

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Correct Answer is D

Explanation

Choice A reason: Acetaminophen reduces pain but is secondary to preventing infection and bleeding with petrolatum dressings. Dressings are the immediate post-circumcision priority to protect the surgical site, per circumcision care and infection control protocols in neonatal nursing practice.

Choice B reason: Wrapping in blankets maintains warmth but does not address the surgical site’s immediate needs. Petrolatum dressings prevent infection and adhesion, critical post-circumcision. Warmth is secondary, per circumcision care and neonatal thermoregulation standards in nursing practice.

Choice C reason: Offering a glucose-dipped pacifier soothes but does not protect the circumcision site from infection or bleeding. Petrolatum dressings are the priority to ensure healing and comfort, per circumcision care and postoperative pain management standards in neonatal nursing practice.

Choice D reason: Applying petrolatum gauze dressings prevents infection, promotes healing, and reduces adhesion of the circumcision site to diapers. This is the priority intervention to protect the surgical wound, per evidence-based circumcision care and infection control protocols in neonatal nursing practice.

A. Dependence. B. Interaction. C. Toxicity. D. Tolerance.

Correct Answer is C

Explanation

Choice A reason: Dependence is not a primary concern with lithium, a mood stabilizer. Toxicity is critical due to lithium’s narrow therapeutic range, risking severe complications. Dependence is more relevant to other drugs, per psychopharmacology and lithium therapy education standards in nursing.

Choice B reason: Interactions are important but less urgent than toxicity, which can be life-threatening with lithium’s narrow therapeutic index. Toxicity education emphasizes monitoring blood levels to prevent harm, per psychopharmacology and patient safety protocols in lithium therapy teaching.

Choice C reason: Toxicity is the most critical adverse effect to teach, as lithium’s narrow therapeutic index risks severe complications like seizures or renal failure. Monitoring symptoms and blood levels ensures safety, per evidence-based psychopharmacology and patient education protocols for lithium therapy in nursing.

Choice D reason: Tolerance is not a significant issue with lithium, unlike toxicity, which is life-threatening due to its narrow therapeutic range. Teaching toxicity symptoms prioritizes patient safety, per lithium therapy management and psychopharmacological education standards in nursing practice.

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The nurse measures the client’s blood pressure (BP) and notes that it is significantly higher than the previous reading. Which should the nurse do next? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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Correct Answer is C

Explanation

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