Vital Signs Measurement > Fundamentals
Exam Review
Blood Pressure Measurement:
Total Questions : 5
Showing 5 questions, Sign in for moreA nurse is assessing a client's blood pressure. Which of the following should the nurse use to measure blood pressure accurately?
Explanation
Answer: d. Measurement using a sphygmomanometer and stethoscope
Explanation: To accurately measure blood pressure, the nurse should use a sphygmomanometer and stethoscope. This allows for the auscultatory method of blood pressure measurement, which involves listening for Korotkoff sounds to determine systolic and diastolic blood pressure.
a. Palpation of the client's radial pulse provides information about the pulse rate but does not accurately measure blood pressure.
b. Auscultation of lung sounds assesses respiratory function but does not directly measure blood pressure.
c. Visual observation of skin color can provide information about circulation but does not provide an accurate measurement of blood pressure.
A nurse is assessing a client's blood pressure and finds it to be 160/90 mmHg. What action should the nurse take?
Explanation
Answer: c. Initiate antihypertensive medication.
Explanation: A blood pressure reading of 160/90 mmHg indicates hypertension (high blood pressure). The nurse should initiate antihypertensive medication and implement other interventions as appropriate to manage and control blood pressure.
a. Documenting the blood pressure as normal would be inaccurate since it exceeds the normal range.
b. Rechecking the blood pressure after 30 minutes may delay appropriate intervention if the blood pressure remains elevated.
d. Instructing the client to increase salt intake is not appropriate for managing hypertension, as sodium intake can exacerbate high blood pressure.
A nurse is assessing a client's blood pressure and finds it to be 90/60 mmHg. What action should the nurse take?
Explanation
Answer: a. Document the blood pressure as normal.
Explanation: A blood pressure reading of 90/60 mmHg is within the normal range for some individuals, especially those with low-normal blood pressure. The nurse should document the blood pressure as normal and consider the client's overall health and clinical condition.
b. Rechecking the blood pressure after 1 hour is not necessary unless there are specific concerns or symptoms indicating a need for further assessment.
c. Initiating intravenous fluid therapy is not indicated solely based on a blood pressure reading within the normal range.
d. Administering a vasopressor medication is not appropriate based solely on a blood pressure reading within the normal range.
A nurse is assessing a client's blood pressure and finds it to be different in the two arms. What action should the nurse take?
Explanation
Answer: c. Report the findings to the healthcare provider. Explanation: A significant difference in blood pressure readings between the two arms may indicate an underlying vascular or arterial problem. The nurse should report the findings to the healthcare provider for further evaluation and intervention.
a. Documenting the finding as a normal variation would be inappropriate since it may indicate an underlying vascular or arterial issue.
b. Rechecking the blood pressure using the arm with the higher reading may be considered, but reporting the findings to the healthcare provider is the priority for further evaluation.
d. Instructing the client to raise both arms above the head is not necessary and does not address the potential underlying issue with blood pressure readings in different arms.
A nurse is assessing a client's blood pressure and finds it to be 140/90 mmHg on multiple occasions. What action should the nurse take?
Explanation
Answer: c. Initiate lifestyle modifications and monitor blood pressure.
Explanation: A blood pressure reading of 140/90 mmHg on multiple occasions indicates stage 1 hypertension. The nurse should initiate lifestyle modifications, such as diet changes, exercise, and stress reduction, and closely monitor the client's blood pressure. Antihypertensive medication may be considered if lifestyle modifications are not effective.
a. Documenting the blood pressure as normal would be inaccurate since it exceeds the normal range.
b. Rechecking the blood pressure after 1 week may delay appropriate intervention if the blood pressure remains elevated.
d. Administering anticoagulant medication is not indicated solely based on an elevated blood pressure reading.
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