Which blood pressure (BP) finding by the nurse indicates that no changes in therapy are needed for a 48-year-old patient with newly diagnosed hypertension?
128/76 mm Hg
148/78 mm Hg
98/56 mm Hg
128/92 mm Hg
The Correct Answer is A
Choice A reason: A blood pressure of 128/76 mm Hg is within the target range for a patient with hypertension, indicating that the current therapy is effectively managing the condition. This reading is below the generally accepted threshold for hypertension, which is 140/90 mm Hg.
Choice B reason: A blood pressure of 148/78 mm Hg is above the target range for hypertension management. This reading suggests that the patient may need an adjustment in their therapy to better control their blood pressure and reduce the risk of cardiovascular complications.
Choice C reason: A blood pressure of 98/56 mm Hg is too low and may indicate hypotension, which can be a concern, especially if the patient experiences symptoms like dizziness or fainting. This reading suggests that the patient's therapy may need to be adjusted to avoid excessively lowering blood pressure.
Choice D reason: A blood pressure of 128/92 mm Hg shows an elevated diastolic pressure, which is above the target range. This indicates that the patient's hypertension is not fully controlled, and adjustments in therapy may be needed to bring both systolic and diastolic pressures within the desired range.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Teaching the patient to use guided imagery can be an effective pain management strategy, but it might not be the most immediate and reassuring intervention for a patient experiencing fear about postoperative pain. This approach is more useful as an additional technique rather than the primary intervention.
Choice B reason: Describing the type of pain expected with the patient's particular surgery can provide some insight into what to anticipate, but it does not necessarily alleviate fear or provide concrete strategies for managing pain. It might even increase anxiety by focusing on the details of the pain itself.
Choice C reason: Explaining the pain management plan, including the use of a pain rating scale, is the most effective intervention. This approach directly addresses the patient's concerns by providing them with a clear understanding of how their pain will be managed and controlled postoperatively. Knowing that there is a structured plan in place, with specific methods to assess and manage pain, helps build confidence and reduces fear. The use of a pain rating scale also empowers the patient to communicate their pain levels effectively, ensuring timely and appropriate interventions.
Choice D reason: Informing the patient that pain medication will be available is helpful, but it lacks the detail and comprehensive approach of explaining the entire pain management plan. Patients may still have concerns about how their pain will be assessed and addressed specifically.
Correct Answer is ["B","C","D","E"]
Explanation
Choice A reason: Dementia is not a typical complication directly related to the post-operative period of a total hip replacement. While elderly patients may have underlying cognitive issues, dementia is not considered a direct post-op complication.
Choice B reason: Venous thromboembolism (VTE) is a common post-operative complication, particularly in orthopedic surgeries like total hip replacement. Due to immobility and surgical stress, patients are at higher risk for blood clots forming in the veins, which can be life-threatening if they travel to the lungs.
Choice C reason: Fluid overload can occur due to the administration of intravenous fluids during surgery. Monitoring for signs of fluid overload, such as swelling, shortness of breath, and increased blood pressure, is crucial to ensure proper fluid balance and prevent complications like heart failure.
Choice D reason: Infection is a significant risk after surgery, especially in procedures like total hip replacement. Monitoring for signs of infection, such as fever, increased pain, redness, swelling, and drainage from the surgical site, is essential to detect and treat infections early.
Choice E reason: Unrelieved pain is a critical aspect to monitor post-operatively. Effective pain management is crucial for patient comfort, mobility, and recovery. Uncontrolled pain can impede rehabilitation and recovery, increasing the risk of complications.
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