Nokea
A female patient with chronic hypertension is admitted to the emergency department with a sudden rise in blood pressure (BP). Which question is the priority for the nurse to ask the patient?
- A. Are you pregnant?
- B. Do you need to urinate?
- C. Do you have a headache or confusion?
- D. Are you taking antiseizure medications?
Correct Answer: C
Rationale: A sudden rise in blood pressure can indicate a hypertensive crisis, and assessing for neurological symptoms like headache or confusion is crucial to identify potential target organ damage.
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The blood pressure (BP) of a 71-year-old patient admitted with pneumonia is 160/70 mm Hg. Which age-related change contributes to this finding?
- A. Stenosis of the heart valves.
- B. Decreased adrenergic sensitivity.
- C. Increased parasympathetic activity.
- D. Loss of elasticity in arterial vessels.
Correct Answer: D
Rationale: Loss of elasticity in arterial vessels due to aging causes increased systolic blood pressure, as seen in the 160/70 mm Hg reading.
The nurse receives a health care provider's prescription to change a patient's IV from D5. half-normal saline with 40 mEq KCl/L to DSNS with 20 mEq KCl/L. Which set of serum laboratory values supports the rationale for this IV prescription change?
- A. Sodium level of 136 mEq/L, potassium level of 4.5 mEq/L.
- B. Sodium level of 145 mEq/L, potassium level of 4.8 mEq/L.
- C. Sodium level of 135 mEq/L, potassium level of 3.6 mEq/L.
- D. Sodium level of 144 mEq/L, potassium level of 3.7 PROTOCOL mEq/L.
Correct Answer: C
Rationale: Normal sodium (135 mEq/L) and potassium (3.6 mEq/L) levels support changing to a lower potassium IV (20 mEq KCl/L) to prevent hyperkalemia while maintaining hydration.
With which term will the nurse document the finding after noting multiple 1-mm red macules when assessing the skin of a patient with leukemia and thrombocytopenia?
- A. Purpura.
- B. Bruising.
- C. Petechiae.
- D. Ecchymosis.
Correct Answer: C
Rationale: Petechiae are small, red or purple 1-mm macules due to minor bleeding from broken capillaries, common in thrombocytopenia.
Which finding would the nurse expect to see in a patient with a hemoglobin level of 8 g/dL? Select all that apply.
- A. Palpitations.
- B. Conjunctival pallor.
- C. Sternal tenderness.
- D. Heart rate of 104 beats/min.
Correct Answer: B,D
Rationale: Conjunctival pallor and increased heart rate (104 beats/min) are expected in anemia due to reduced oxygen-carrying capacity and compensatory tachycardia.
The nurse notes that there is a difference in a patient's blood pressure (BP) and heart rate (HR) when the patient changes position from supine to standing. The differences are a decrease of 20 mm Hg in systolic BP, a decrease of 10 mm Hg in diastolic BP, and an increase in the HR of 20 beats/minute. Which interpretation would the nurse make about the patient's condition?
- A. Hypertensive crisis.
- B. An auscultatory gap.
- C. Resistant hypertension.
- D. Enlarged lymph nodes.
Correct Answer: B
Rationale: The described changes suggest an auscultatory gap, a phenomenon during BP measurement that can lead to inaccurate readings, requiring careful technique.