PN FUNDAMENTALS UPDATED 2024 EXAM
PN FUNDAMENTALS UPDATED 2024 EXAM ( 53 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 126/72 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?
Deflate the cuff faster when repeating the BP measurement is incorrect.
The method of deflating the cuff faster is not a solution for accurately measuring blood pressure. It's essential to ensure proper technique and a standard approach to obtaining accurate readings.
Measure the client's BP in the other arm is incorrect. While comparing blood pressure readings between arms can sometimes provide useful information, in this situation, the substantial increase in blood pressure is concerning and may need immediate attention rather than rechecking in another arm first.
Use a narrower cuff to repeat the BP measurement is incorrect. Using an incorrectly sized cuff can lead to inaccurate blood pressure readings. However, the sudden significant increase in blood pressure is an urgent issue that requires attention and potential intervention rather than changing the cuff size for measurement.
Request a prescription for an antihypertensive medication is correct. The significant increase in blood pressure warrants attention, and if it remains elevated and unexplained, it may require medical intervention to manage and prevent potential complications related to hypertension.
Choice A Reason:
Deflate the cuff faster when repeating the BP measurement is incorrect.
The method of deflating the cuff faster is not a solution for accurately measuring blood pressure. It's essential to ensure proper technique and a standard approach to obtaining accurate readings.
Choice B Reason:
Measure the client's BP in the other arm is incorrect. While comparing blood pressure readings between arms can sometimes provide useful information, in this situation, the substantial increase in blood pressure is concerning and may need immediate attention rather than rechecking in another arm first.
Choice C Reason:
Use a narrower cuff to repeat the BP measurement is incorrect. Using an incorrectly sized cuff can lead to inaccurate blood pressure readings. However, the sudden significant increase in blood pressure is an urgent issue that requires attention and potential intervention rather than changing the cuff size for measurement.
Choice D Reason:
Request a prescription for an antihypertensive medication is correct. The significant increase in blood pressure warrants attention, and if it remains elevated and unexplained, it may require medical intervention to manage and prevent potential complications related to hypertension.