The nurse is caring for a patient with an arterial monitoring system. The nurse assesses the patient's noninvasive cuff blood pressure to be 70/40 mm Hg
The arterial blood pressure measurement via an intraarterial catheter in the same arm is assessed by the nurse to be 108/70 mm Hg. What is the best action by the nurse? a. Activate the rapid response system.
b. Place the patient in Trendelenburg position.
c. Assess the cuff for proper arm size.
d. Administer 0.9% normal saline bolus.
C
Under normal circumstances, a difference of 10 to 20 mm Hg or more between invasive and noninvasive blood pressure is expected, with the invasive value being higher than the noninvasive value. The cuff used for noninvasive measurement should be assessed for proper cuff size. Given that the invasive value is substantially higher, before initiating corrective actions based on a single noninvasive measurement, such as activating the rapid response system, placing the patient in Trendelenburg position, or administering a fluid bolus, further assessment and troubleshooting are necessary.
You might also like to view...
A factory abruptly closes. An office worker initially tries to take it in stride, begins the job search, and networks with peers. Five weeks later, he has not received a single call-back from a prospective employer
He cannot sleep, is irritable, does not want to interact with his family or peers, paces, and spends several hours most days alone in a local bar. He has given up applying for jobs. Which three nursing diagnoses would be the highest priority at this time? Select all that apply. a. Risk for self-injury b. Risk for compromised resilience c. Ineffective denial d. Ineffective coping e. Chronic low self-esteem f. Social isolation
A patient will be receiving busulfan (Myleran) as treatment for leukemia. Which interventions should the nurse include in the patient's plan of care? Note: Credit will be given only if all correct choices and no incorrect choices are selected
Select all that apply. 1. Assess for infection. 2. Monitor for hearing loss. 3. Monitor for a decrease in BUN level. 4. Institute fall precautions. 5. Reduce the amount of sodium in the patient's diet.
The nurse is caring for a client who has been given one year to live. Which of the following is a useful nursing intervention to treat the anxiety of the client and family associated with receiving a terminal diagnosis?
1. Explore the client and family's history with other stressful life events and how successful coping was at that time 2. Teach the family that while talking with the client about death and dying is permissible, they should not allow the client to dwell on death 3. Supply information about the client's disease process and the expected trajectory of death only on a need to know basis 4. Encourage early pharmaceutical intervention with anti-anxiety and sedative medications
A 4-year-old child is hospitalized with a serious bacterial infection. The child tells the nurse that he is sick because he was "bad." Which is the nurse's best interpretation of this comment?
a. Sign of stress b. Common at this age c. Suggestive of maladaptation d. Suggestive of excessive discipline at home