Nokea
The nursing lab instructor is teaching student nurses how to take blood pressure. To ensure accurate measurement, the lab instructor would teach the students to avoid which of the following actions?
- A. Measuring the BP after the patient has been seated quietly for more than 5 minutes
- B. Taking the BP at least 10 minutes after nicotine or coffee ingestion
- C. Using a cuff with a bladder that encircles at least 80% of the limb
- D. Using a bare forearm supported at heart level on a firm surface
Correct Answer: B
Rationale: Blood pressures should be taken with the patient seated with arm bare, supported, and at heart level. The patient should not have smoked tobacco or taken caffeine in the 30 minutes preceding the measurement. The patient should rest quietly for 5 minutes before the reading is taken. The cuff bladder should encircle at least 80% of the limb being measured and have a width of at least 40% of limb circumference. Using a cuff that is too large results in a lower BP and a cuff that is too small will give a higher BP measurement.
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A patient in hypertensive emergency is being cared for in the ICU. The patient has become hypovolemic secondary to natriuresis. What is the nurses most appropriate action?
- A. Add sodium to the patients IV fluid, as ordered
- B. Administer a vasoconstrictor, as ordered
- C. Promptly cease antihypertensive therapy
- D. Administer normal saline IV, as ordered
Correct Answer: D
Rationale: If there is volume depletion secondary to natriuresis caused by the elevated BP, then volume replacement with normal saline can prevent large, sudden drops in BP when antihypertensive medications are administered. Sodium administration, cessation of antihypertensive therapy, and administration of vasoconstrictors are not normally indicated.
The nurse is screening a number of adults for hypertension. What range of blood pressure is considered normal?
- A. Less than 140/90 mm Hg
- B. Less than 130/90 mm Hg
- C. Less than 129/89 mm Hg
- D. Less than 120/80 mm Hg
Correct Answer: D
Rationale: JNC 7 defines a blood pressure of less than 120/80 mm Hg as normal, 120 to 129/80 to 89 mm Hg as prehypertension, and 140/90 mm Hg or higher as hypertension.
The hospital nurse cares for many patients who have hypertension. What nursing diagnosis is most common among patients who are being treated for this health problem?
- A. Deficient knowledge regarding the lifestyle modifications for management of hypertension
- B. Noncompliance with therapeutic regimen related to adverse effects of prescribed therapy
- C. Deficient knowledge regarding BP monitoring
- D. Noncompliance with treatment regimen related to medication costs
Correct Answer: B
Rationale: Deviation from the therapeutic program is a significant problem for people with hypertension and other chronic conditions requiring lifetime management. For many patients, this is related to adverse effects of medications. Medication cost is relevant for many patients, but adverse effects are thought to be a more significant barrier. Many patients are aware of necessary lifestyle modification, but do not adhere to them. Most patients are aware of the need to monitor their BP.
A patient in a hypertensive emergency is admitted to the ICU. The nurse anticipates that the patient will be treated with IV vasodilators, and that the primary goal of treatment is what?
- A. Lower the BP to reduce onset of neurologic symptoms, such as headache and vision changes
- B. Decrease the BP to a normal level based on the patients age
- C. Decrease the mean arterial pressure between 20% and 25% in the first hour of treatment
- D. Reduce the BP to 120/75 mm Hg as quickly as possible
Correct Answer: C
Rationale: Initially, the treatment goal in hypertensive emergencies is to reduce the mean arterial pressure by 25% in the first hour of treatment, with further reduction over the next 24 hours. Lowering the BP too fast may cause hypotension in a patient whose body has adjusted to hypertension and could cause a stroke, MI, or visual changes. Neurologic symptoms should be addressed, but this is not the primary focus of treatment planning.
The nurse is reviewing the medication administration record of a patient who takes a variety of medications for the treatment of hypertension. What potential therapeutic benefits of antihypertensives should the nurse identify? Select all that apply.
- A. Increased venous return
- B. Decreased peripheral resistance
- C. Decreased blood volume
- D. Decreased strength and rate of myocardial contractions
- E. Decreased blood viscosity
Correct Answer: B,C,D
Rationale: The medications used for treating hypertension decrease peripheral resistance, blood volume, or the strength and rate of myocardial contraction. Antihypertensive medications do not increase venous return or decrease blood viscosity.