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 A

Explanation

Choice A reason: Oatmeal, raisins, and fruit with skin are high in fiber, reducing colorectal cancer risk by promoting bowel regularity and reducing carcinogen exposure. This aligns with dietary prevention strategies, per oncology and gastrointestinal health guidelines in nursing education.

Choice B reason: Potatoes, low-fat breads, and applesauce are low in fiber, offering less protection against colorectal cancer. High-fiber foods like oatmeal and fruit are preferred to reduce risk, per dietary recommendations and cancer prevention protocols in nursing care.

Choice C reason: Chicken, rice, and wheat products provide moderate fiber but lack the high-fiber content of oatmeal and fruit with skin, which better reduce colorectal cancer risk. Fiber is key, per oncology and dietary prevention standards in nursing education.

Choice D reason: Lean beef, salads, and baked potatoes offer some benefits, but beef may increase cancer risk. High-fiber oatmeal, raisins, and fruit are more effective for prevention, per colorectal cancer dietary guidelines and oncology prevention protocols in nursing care.

A. Measure capillary glucose level. B. Monitor for bloody diarrheal stools. C. Obtain vital signs measurements. D. Encourage ambulation in the room.

Correct Answer is C

Explanation

Choice A reason: Measuring glucose monitors corticosteroid-induced hyperglycemia, but a rigid abdomen with rebound tenderness suggests peritonitis, possibly from IBD-related perforation. Vital signs detect systemic effects like sepsis (e.g., tachycardia), more urgent than glucose, as perforation is a life-threatening emergency requiring immediate intervention to prevent shock.

Choice B reason: Monitoring bloody diarrhea is relevant in IBD, but a rigid abdomen with rebound tenderness indicates peritonitis, likely from perforation. Vital signs assess systemic stability (e.g., fever, hypotension), critical for detecting life-threatening complications like sepsis, making this more urgent than tracking expected IBD symptoms.

Choice C reason: A rigid abdomen with rebound tenderness suggests peritonitis from bowel perforation in IBD, causing peritoneal irritation. Vital signs (e.g., heart rate, BP, temperature) detect shock or infection, guiding urgent interventions like surgery or antibiotics. This assessment prioritizes rapid response to a potentially fatal surgical emergency.

Choice D reason: Encouraging ambulation is contraindicated with a rigid abdomen and rebound tenderness, indicating peritonitis. Movement may worsen peritoneal irritation or infection spread. Vital signs assess systemic compromise, critical for managing perforation, ensuring timely intervention to prevent sepsis or shock, making ambulation inappropriate.

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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

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