Blood pressure

Which adult patient's blood pressure reading would the nurse realize is unexpected? 100/60 116/78 96/64 to 118/74 108/70 to 118/79

96/64 to 118/74 Rational: A 20 to 30 mm Hg change (either upward or downward) in either the systolic or diastolic reading when compared to an earlier reading is an unexpected finding, even though the individual readings are within the expected range.

Which statements indicate the nurse understands possible errors in blood pressure assessment? Select all that apply. "A noisy environment can cause a false low reading." "If the cuff is too wide, a false high reading is possible." "If pressure is released too slowly, a false high reading is possible." "A patient's arm should be above heart level to avoid a false low reading." "Reinflating the cuff bladder before it has completely deflated can cause a false high measurement."

A noisy environment can cause a false low reading." If pressure is released too slowly, a false high reading is possible." Reinflating the cuff bladder before it has completely deflated can cause a false high measurement."

Which actions would the nurse take for a patient with low blood pressure from decreased peripheral vascular resistance? Select all that apply. Administer prescribed antihypertensive medications. Administer prescribed intravenous (IV) fluids. Administer prescribed oxygen. Position supine with legs elevated. Position prone with head on small pillow.

Administer prescribed Intravenous (IV) fluids. Administer prescribed Oxygen Position supine with legs elevated.

Which blood pressure measurement is an unexpected finding? Newborn: 70/40 6-year-old: 90/60 15-year-old: 110/68 Adult: 128/84

Adult: 128/84 This is an unexpected finding because the expected blood pressure for an adult is 90-<120 over 60-<80; this patient's blood pressure is 128/84.

Which factor would the nurse consider is likely causing hypertension in an older adult female who is 5'4", weighs 100 lbs (45.4 kg), drinks an occasional glass of red wine before bed, and limits salt in her diet? Age Obesity Alcohol use Salt intake

Age

Which interventions would the nurse implement to help an obese adult patient who smokes cigarettes successfully manage hypertension? Select all that apply. Arranging for nutritional support Encouraging cessation of smoking Monitoring responses to prescribed antihypertensive medications Comparing current blood pressure readings to original readings Listening while the patient expresses gratitude for care

Arranging for nutritional support encouraging cessation of smoking Monitoring responses to prescribed antihypertensive medication.

Which cues would the nurse observe in a patient with a blood pressure of 60/40 and shock? Select all that apply. Clammy skin Thready pulse Increased urinary output Confusion Bradycardia

Clammy skin Thready pulse Confusion

Match the blood vessel or mechanism of blood pressure regulation to its function. Controls delivery of blood to organs, tissues, and cells Manages mechanisms used for short-term blood pressure regulation Allows a continuous flow of blood into capillaries Releases in response to low blood pressure to retain water Arterioles Autonomic Nervous System Arteries Antidiuretic Hormone

Controls delivery of blood to organs, tissues, and cells Arterioles Manages mechanisms used for short-term blood pressure regulation Autonomic Nervous System Allows a continuous flow of blood into capillaries Arteries Releases in response to low blood pressure to retain water. Anitdiurtic Hormone (ADH)

Which factor would the nurse suspect is causing the blood pressure to fall when a patient who experienced a myocardial infarction (heart attack) is becoming cool and clammy? Extreme vasodilation Increased blood volume Decreased cardiac output Increased peripheral vascular resistance

Decreased cardiac output Decreased cardiac output is a physiologic factor of hypotension and is caused by a myocardial infarction.

Which actions would the nurse take when manually measuring the patient's brachial blood pressure? Select all that apply. Deflate cuff at a rate of 2 mm Hg/second. Inflate cuff 30 mm Hg above the previous systolic reading. Place cuff loosely around the upper arm. Position cuff 2.5 cm (1 inch) above the antecubital fossa. Allow the patient to sit and cross legs.

Deflate cuff at a rate of 2mm Hg/second Inflate cuff 30 mm Hg above the previous systolic reading. Rationale is a recommended practice for measuring brachial blood pressure. Position cuff 2.5 cm (1 inch) above the antecubital fossa

For which patients would the nurse measure blood pressure with an electronic device? Select all that apply. Has a regular heartbeat Is shivering Experiences seizure activity Has a previous systolic blood pressure reading of 86 mm Hg Has a previous systolic blood pressure reading of 140 mm Hg

Has a regular Heart beat The nurse can use the electronic device with a patient who has a regular heartbeat; the electronic device is not used when the patient's heartbeat is irregular. Has a previous systolic blood pressure reading of 140 mm Hg The nurse can use the electronic device with a patient who has a previous systolic blood pressure reading of 140 mm Hg.

Match the blood pressure measurement to its classification. Hypertension stage 1 Elevated Hypertension stage 2 130-139 systolic <120 systolic <80 diastolic with systolic 120-129 ≥90 diastolic

Hypertension stage 1 130 - 139 systolic Elevated <80 diastolic with systolic 120-129 Hypertension stage 2 >90 diastolic or greater

Which actions would the nurse take for a patient with the following blood pressures: 119/74, 125/78, 130/83, and 135/88? Select all that apply. Measure oxygen saturation level. Monitor blood pressure every 4 hours. Reassess the circulatory system. Perform a head-to-toe assessment. Notify health care provider.

Measure Oxygen saturation level Reassess the circulatory system Performed head-to-toe assessment Notify health care provider

Which information would the nurse share with a team member about the pathophysiology of hypertension? Vasoconstriction causes blood to pool in the lower extremities, making the heart pump harder. Enlarging of the blood vessels with no rise in cardiac output leads to increased blood pressure. Narrowing of the arteries causes decreased peripheral resistance, leading to higher blood pressure. Overstimulation of angiotensin and aldosterone causes the blood pressure to increase.

Overstimulation of angiotensin and aldosterone causes the blood pressure to increase from neurohormonal dysfunction, leading to hypertension.

Which site would the nurse use to measure blood pressure when the patient's upper body is severely burned? Popliteal Brachial Radial Femoral

Popliteal

Which hypothesis would the nurse select for a patient with a blood pressure of 130/70 who when sitting up becomes dizzy and the blood pressure is 108/60? Shock Postural hypotension Hypertension stage 1 Hypotension

Postural hypotension The patient has orthostatic, or postural, hypotension since this event of hypotension occurred when moving from a supine to a sitting position.

Which patient cue would the nurse identify as relevant for blood pressure? Reports blurred vision Is married Had abdominal surgery 5 years ago Has periods of intense hunger

Reports blurred vision.

Which finding would alert the nurse that a patient with a blood pressure of 80/40 is improving? Skin becomes warm and dry. Blood pressure decreases. DASH diet is consumed. Stress level decreases.

Skin becomes warm and dry

Which action by the nurse when caring for a patient with a left mastectomy would cause the charge nurse to intervene? Takes the blood pressure in the left arm Uses a cuff width that is 40% of the circumference of the arm Listens for the first Korotkoff sound to record as the systolic pressure Makes sure the cuff bladder is 60% to 80% of the arm circumference

Takes the blood pressure in the left arm

Which information is accurate about blood pressure? Blood pressure is measured by subtracting the diastolic from the systolic pressure. The numerator is the diastolic pressure. Blood pressure is the force against the venous walls. The heart exerts maximum pressure during contractions.

The heart exerts maximum pressure during contractions. The heart exerts maximum pressure, the systolic pressure, during contractions.