ATI PN FUNDAMENTALS UPDATED 2023
ATI PN FUNDAMENTALS UPDATED 2023 ( 41 Questions)
A nurse on a medical-surgical unit is collecting data from a client who is postoperative following abdominal surgery. The client's BP was 125/85 mm Hg 15 min ago. The nurse now finds that the client’s BP is 176/96 mm Hg. Which of the following actions should the nurse take?
Using a narrower cuff to repeat the BP measurement is an incorrect action by the nurse, as it can result in a falsely high reading. The nurse should use a cuff that fits the client's arm size and circumference.
Measuring the client's BP in the other arm is the correct action by the nurse, as it can help to confirm the accuracy of the reading and rule out any possible errors or variations. The nurse should compare the readings from both arms and report any significant differences to the provider.
Deflating the cuff faster when repeating the BP measurement is an incorrect action by the nurse, as it can result in a falsely low reading. The nurse should deflate the cuff at a rate of 2 to 3 mm Hg per second.
Requesting a prescription for an antihypertensive medication is an inappropriate action by the nurse, as it is premature and unnecessary. The nurse should first verify the BP reading and identify the possible causes of the elevation, such as pain, anxiety, or medication effects. The nurse should also implement nonpharmacological interventions, such as positioning, relaxation, and oxygen therapy, before administering any medication.
Choice A reason: Using a narrower cuff to repeat the BP measurement is an incorrect action by the nurse, as it can result in a falsely high reading. The nurse should use a cuff that fits the client's arm size and circumference.
Choice B reason: Measuring the client's BP in the other arm is the correct action by the nurse, as it can help to confirm the accuracy of the reading and rule out any possible errors or variations. The nurse should compare the readings from both arms and report any significant differences to the provider.
Choice C reason: Deflating the cuff faster when repeating the BP measurement is an incorrect action by the nurse, as it can result in a falsely low reading. The nurse should deflate the cuff at a rate of 2 to 3 mm Hg per second.
Choice D reason: Requesting a prescription for an antihypertensive medication is an inappropriate action by the nurse, as it is premature and unnecessary. The nurse should first verify the BP reading and identify the possible causes of the elevation, such as pain, anxiety, or medication effects. The nurse should also implement nonpharmacological interventions, such as positioning, relaxation, and oxygen therapy, before administering any medication.