The nurse on the intermediate care unit received change-of-shift report on four clients with hypertension. Which patient should the nurse assess ﬁrst?

A client with a blood pressure of 190/92 mm Hg who reports chest pain

A client with a blood pressure of 190/104 mm Hg who has sinus tachycardia

A client with a blood pressure of 178/90 mm Hg who has intermittent claudication

A client with a blood pressure of 172/98 mm Hg scheduled for a stress test

Answer and Explanation

The Correct Answer is A

The nurse should assess the client with a blood pressure of 190/92 mm Hg who reports chest pain ﬁrst. Chest pain can be a symptom of myocardial ischemia or a heart attack, which requires immediate attention. The combination of high blood pressure and chest pain is concerning and may indicate acute coronary syndrome. Prompt assessment and intervention are crucial to evaluate the cause of the chest pain and initiate appropriate treatment.

A client with a blood pressure of 190/104 mm Hg who has sinus tachycardia: While sinus tachycardia may indicate increased heart rate, it does not necessarily require immediate assessment unless other concerning symptoms are present. However, the nurse should address the elevated blood pressure in a timely manner.

Intermittent claudication refers to leg pain or discomfort during physical activity due to reduced blood ﬂow. While it is important to assess and manage this symptom, it is not typically considered an urgent condition requiring immediate assessment compared to chest pain.

The client scheduled for a stress test may have elevated blood pressure, but if they are stable and not currently experiencing symptoms, they may not require immediate assessment compared to a client with chest pain.

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Free Nursing Study Resources

Correct Answer is ["B","C","D","E"]

Explanation

Pain level of 10 out of 10: Severe pain can stimulate the sympathetic nervous system and result in an increased heart rate.

Temperature 101.9°F: Fever can lead to an elevated heart rate as the body's response to infection or inﬂammation.

Hemoglobin: 7 g/dL: Low hemoglobin levels, known as anemia, can cause the heart to pump faster in an attempt to compensate for the decreased oxygen-carrying capacity of the blood.

Cocaine abuse: Cocaine is a stimulant drug that can signiﬁcantly increase heart rate and cause tachycardia.

The following clinical ﬁnding would not typically be associated with tachycardia:

Blood glucose 90 mg/dL: While low or high blood glucose levels can cause symptoms, they are not directly associated with tachycardia unless they lead to signiﬁcant physiological stress or hormonal imbalances.

A. 128/76 mm Hg B. 128/92 mm Hg C. 98/56 mm Hg D. 142/78 mm Hg

Correct Answer is A

Explanation

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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The nurse on the intermediate care unit received change-of-shift report on four clients with hypertension. Which patient should the nurse assess ﬁrst?

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Naxlex Comprehensive Predictor Exams

The nurse is assessing a client with a heart rate of 124 bpm. What clinical ﬁnding(s) should the nurse assess as causes of tachycardia? Select all that apply.

Correct Answer is ["B","C","D","E"]

Explanation

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Correct Answer is A

Explanation

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