The nursing assistant informs the nurse that the patient's blood pressure is 220/102 using the electronic monitor. What is the priority action of the nurse?
Inform the patient's health care provider immediately to obtain an order for antihypertensive medications.
Instruct the nursing assistant to take the patient's blood pressure again and inform the nurse of the results immediately.
Take the patient's blood pressure manually with a sphygmomanometer and stethoscope.
Perform a neurological assessment to determine if the patient is stressed, in pain, or having a stroke.
The Correct Answer is C
A. Inform the patient's health care provider immediately to obtain an order for antihypertensive medications. While notifying the provider may be necessary, the nurse must first confirm the accuracy of the blood pressure reading before taking further action.
B. Instruct the nursing assistant to take the patient's blood pressure again and inform the nurse of the results immediately. Nursing assistants can take blood pressure readings, but the nurse should personally verify a critically high reading using a manual method.
C. Take the patient's blood pressure manually with a sphygmomanometer and stethoscope. Electronic monitors can sometimes give false readings, especially in patients with irregular heartbeats or movement. Manually verifying ensures an accurate assessment before determining further action.
D. Perform a neurological assessment to determine if the patient is stressed, in pain, or having a stroke. A neurological assessment is important if the elevated BP is confirmed, but the first priority is verifying the reading manually.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Bradypnea refers to an abnormally slow respiratory rate, typically below 12 breaths per minute in an adult. A rate of 32 breaths/min is too fast to be considered bradypnea.
B. Apnea is the absence of breathing for a prolonged period. Since the patient has a respiratory rate of 32 breaths/min, apnea does not apply.
C. Tachypnea is defined as a rapid respiratory rate exceeding 20 breaths per minute in an adult. A rate of 32 breaths/min indicates tachypnea, which may be caused by conditions such as fever, anxiety, or respiratory distress.
D. Eupnea refers to normal breathing, with a respiratory rate between 12–20 breaths per minute. A rate of 32 breaths/min is too high to be considered eupnea.
Correct Answer is ["0.5"]
Explanation
To determine the number of tablets per dose, use the formula:
Tablets per dose = Dose ordered/Dose available
Given:
- Ordered dose = 400 mg
- Available dose = 800 mg per tablet
Tablets per dose = 400mg/(800mg/tablet)
= 0.5 tablet
Thus, the nurse will administer 0.5 tablet per dose.
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