Practice Question
The nurse on the intermediate care unit received change-of-shift report on four clients with hypertension. Which patient should the nurse assess first?
Answer Choices:
Correct Answer:
A client with a blood pressure of 190/92 mm Hg who reports chest pain
Rationale:
🔶 Possible MI/dissection: Chest pain with severe hypertension suggests acute coronary syndrome or aortic catastrophe, both time‑critical.
🔶 Symptom risk: Symptomatic patients take priority over asymptomatic elevated BPs.
🔶 Immediate actions: Obtain ECG, troponin, VS, treat pain, and initiate IV antihypertensive if indicated.
🔶 Other options: Tachycardia alone or scheduled testing lack red‑flag symptoms.
🔶 Outcome impact: Early intervention reduces myocardial damage/mortality.
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This question is from Medical-Surgical Exam 3 which contains 46 questions.
More Questions from This Exam
The nurse is assessing a client with a hypertensive emergency. Which finding is most important to report to the health care provider?
Answer Choices:
A. The client reports a headache with pain at level 5 of 10
B. The client has epistaxis after blowing his nose several times
C. The client has a urine output of 120 mL over a 4 hours
D. The client has a new-onset blurry vision and facial asymmetry
The nurse is assessing a client with a presumptive diagnosis of peripheral arterial disease. The nurse obtains an Ankle-Brachial index of 0.89. Which intervention should the nurse take next?
Answer Choices:
A. Document the information as a normal finding
B. Prepare the client for an arterial bypass
C. Educate the client about the use of compression stocking
D. Anticipate a prescription for clopidogrel and simvastatin
A nurse is assessing a client with a history of high blood pressure. The client's blood pressure is 210/106 mm Hg during the assessment. What follow-up question should the nurse ask?
Answer Choices:
A. "Have you recently taken any antihistamines?"
B. "Have there been recent stressful events in your life?"
C. "Did you take any acetaminophen today?"
D. "Have you consistently taken your medications?"
The nurse is caring for a client immediately after repair of an abdominal aortic aneurysm. On assessment, the client has absent popliteal, posterior tibial, and dorsalis pedis pulses. The leg cool and mottled. Which action should the nurse take first?
Answer Choices:
A. Wrap both legs in a warming blanket
B. Compare findings to the preoperative assessment of the pulses
C. Document the findings and recheck in 15 minutes.
D. Notify the surgeon and anesthesiologist
The nurse is assessing a client with a heart rate of 124 bpm. What clinical finding(s) should the nurse assess as causes of tachycardia? Select all that apply.
Answer Choices:
A. Blood glucose 90 mg/dL
B. Pain level of 10 out of 10
C. Temperature 101.9 F
D. Hemoglobin: 7g/dl
E. Cocaine abuse
Question Details
- Category: RN Nursing Exam(s)
- Subcategory: General Exams
- Domain: Medical-surgical📚
- Answer Choices: 4