NSG 522 Clinical I Chapter 29, Vital Signs Blood Pressure Quizlet
Question 1 of 20
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Which description would the nurse use when discussing stroke volume?
The elasticity of the arterial system
Compliance refers to the elasticity of the arterial system rather than the description of stroke volume.
The amount of pressure in the arteries in between beats
Diastolic pressure is the amount of pressure in the arteries in between beats rather than the description of stroke volume.
The numeric difference between systolic and diastolic pressure
Pulse pressure is the numeric difference between systolic and diastolic pressure rather than the description of stroke volume.
Correct
The amount of blood injected into the arterial system with each heartbeat
Stroke volume is the volume of blood injected into the arterial system with each heartbeat (ventricles contract).
Question 2 of 20
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Which cues would the nurse observe in a patient with a blood pressure of 60/40 and shock?
Correct
Clammy skin
Clammy skin is a cue for hypotension and shock resulting from a dangerous fall in blood pressure.
Correct
Thready pulse
Thready pulse is a cue for hypotension and shock resulting from a dangerous fall in blood pressure.
Increased urinary output
Decreased, not increased, urinary output is a cue for hypotension and shock from a decrease in blood pressure.
Correct
Confusion
Confusion is a cue for hypotension and shock because of the decreased blood flow to the brain.
Bradycardia
Tachycardia, not bradycardia, occurs with hypotension and shock.
Question 3 of 20
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Which statement indicates the nurse understands possible errors in blood pressure assessment?
Correct
“A noisy environment can cause a false low reading.”
A noisy environment can lead to a false low measurement.
“If the cuff is too wide, a false high reading is possible.”
A wide cuff could cause a false low blood pressure reading; conversely, a cuff that is too narrow can cause a false high reading.
Correct
“If pressure is released too slowly, a false high reading is possible.”
Releasing pressure too slowly can result in a false high blood pressure reading.
“A patient’s arm should be above heart level to avoid a false low reading.”
A patient’s arm above heart level can lead to a false low reading.
Correct
“Reinflating the cuff bladder before it has completely deflated can cause a false high measurement.”
A false high measurement can occur from reinflating the cuff bladder before it has completely deflated.
Question 4 of 20
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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
Although extreme vasodilation can cause hypotension, it is caused by a severe allergic reaction, not from a heart attack.
Increased blood volume
Decreased, not increased, blood volume is a physiologic factor of hypotension and is caused by hemorrhage or blood loss, not from a myocardial infarction.
Correct
Decreased cardiac output
Decreased cardiac output is a physiologic factor of hypotension and is caused by a myocardial infarction.
Increased peripheral vascular resistance
Decreased, not increased, peripheral vascular resistance is a physiologic factor of hypotension.
Question 5 of 20
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Match the type of hypertension to its description.
No known cause
Primary hypertension
Caused by a specific disease
Secondary hypertension
Systolic blood pressure over 140
Hypertension stage 2
Diastolic blood pressure 80–89
Hypertension stage 1
Question 6 of 20
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Which action by the nurse when caring for a patient with a left mastectomy would cause the charge nurse to intervene?
Correct
Takes the blood pressure in the left arm
The charge nurse would intervene because a brachial blood pressure is not used on the arm that is on the side of the mastectomy as this would promote lymphedema (swelling).
Uses a cuff width that is 40% of the circumference of the arm
Using a cuff width that is 40% of the arm circumference is recommended practice.
Listens for the first Korotkoff sound to record as the systolic pressure
The first Korotkoff sound, or the first sound heard, is recorded as the systolic pressure and is recommended practice for measuring blood pressure.
Makes sure the cuff bladder is 60% to 80% of the arm circumference
Making sure the cuff bladder is 60% to 80% of the arm circumference is recommended practice for taking a blood pressure.
Question 7 of 20
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Which interventions would the nurse implement to help an obese adult patient who smokes cigarettes successfully manage hypertension?
Correct
Arranging for nutritional support
Nutritional support is needed because the patient is obese. Weight reduction can help decrease hypertension.
Correct
Encouraging cessation of smoking
Encouraging cessation of smoking is necessary because smoking is a risk factor for hypertension.
Correct
Monitoring responses to prescribed antihypertensive medications
Medication response is important to monitor to establish if the antihypertensive medication is working effectively and is well tolerated by the patient.
Comparing current blood pressure readings to original readings
Comparing current blood pressure readings to the original reading is an evaluation action, not an intervention.
Listening while the patient expresses gratitude for care NSG 522 Clinical I Chapter 29, Vital Signs Blood Pressure Quizlet
Listening to the patient express thankfulness is a part of the evaluation process; it is not an intervention.
Question 8 of 20
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Which site would the nurse use to measure blood pressure when the patient’s upper body is severely burned?
Correct
Popliteal
The popliteal artery, behind the popliteal space in the lower extremity, can be used to assess blood pressure if the upper extremities are injured and cannot be used.
Brachial
The brachial, located in the upper arm, cannot be used because the upper body is severely burned.
Radial
The radial, located in the wrist, cannot be used because the upper body is severely burned.
Femoral
Although the femoral is in the lower body, blood pressure cannot be taken at this site.
Question 9 of 20
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Which adult patient’s blood pressure reading would the nurse realize is unexpected?
100/60
100/60 is an expected blood pressure for an adult. It falls within the typical ranges of 90–<120 over 60–<80. 116/78 116/78 is an expected blood pressure for an adult. It falls within the typical ranges of 90–<120 over 60–<80. Correct 96/64 to 118/74 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. 108/70 to 118/79 Although there are changes in both the systolic and diastolic pressures, it is not a change of 20 to 30 mm Hg. Question 10 of 20 Report content error What is the patient’s pulse pressure (mm Hg) when the blood pressure is 130/70? Record your answer as a whole number. __ mm Hg Your answer: 60 Correct answer: 60 The pulse pressure is the difference between the systolic and diastolic blood pressure: 130 – 70 = 60. Question 11 of 20 Report content error Which actions would the nurse take when manually measuring the patient’s brachial blood pressure? Correct Deflate cuff at a rate of 2 mm Hg/second. Deflating the cuff at a rate of 2 mm Hg/second is recommended practice for measuring a brachial blood pressure. Correct Inflate cuff 30 mm Hg above the previous systolic reading. Inflating the cuff 30 mm Hg above the previous systolic reading is recommended practice for measuring a brachial blood pressure. Place cuff loosely around the upper arm. The cuff is placed snugly around the upper arm rather than loosely. A loosely placed cuff could result in an inaccurate blood pressure reading. Correct Position cuff 2.5 cm (1 inch) above the antecubital fossa. Positioning the cuff 2.5 cm (1 inch) above the antecubital fossa is recommended practice for measuring a brachial blood pressure. Allow the patient to sit and cross legs. Although the patient is allowed to sit, the patient’s legs are uncrossed, not crossed. Question 12 of 20 Report content error For which patients would the nurse measure blood pressure with an electronic device? Correct Has a regular heartbeat 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. Is shivering The nurse cannot use an electronic device when the patient is shivering as it can produce an inaccurate reading. Experiences seizure activity The nurse cannot use an electronic device when the patient is experiencing seizure activity as it can produce an inaccurate reading. Has a previous systolic blood pressure reading of 86 mm Hg The nurse cannot use an electronic device when the patient has a previous systolic blood pressure reading of 86 mm Hg as it can produce an inaccurate reading; the systolic should be at least 90 or above. Correct 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. Question 13 of 20 Report content error Which patient cue would the nurse identify as relevant for blood pressure? Correct Reports blurred vision Blurred vision is relevant because it could indicate high blood pressure. Is married Marital status is not relevant because it does not affect blood pressure. Had abdominal surgery 5 years ago Abdominal surgery is not relevant for blood pressure since it does not affect blood pressure. Has periods of intense hunger Hunger is irrelevant because it does not affect blood pressure. Question 14 of 20 Report content error 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. Vasodilation (not vasoconstriction) causes blood to pool in the lower extremities, making the heart pump harder; vasoconstriction does occur with hypertension, but it increases peripheral resistance, making the heart pump harder. Enlarging of the blood vessels with no rise in cardiac output leads to increased blood pressure. Enlarging (vasodilation) of the blood vessels with no rise in cardiac output leads to decreased, not increased, blood pressure. Narrowing of the arteries causes decreased peripheral resistance, leading to higher blood pressure. Narrowing of the arteries occurs in hypertension, but it causes increased (not decreased) peripheral resistance. Correct 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. Question 15 of 20 Report content error Place the adult patients in the order in which the nurse would prioritize their care from highest priority to lowest priority. Patient with an occluded airway Patient who has a blood pressure of 76/40 Patient with chronic hypertension Patient with blood pressure of 110/64 The sequence is as follows: an occluded airway takes precedence because of airway, breathing, and circulation (ABCs). The patient with hypotension (76/40) is next, followed by the patient with chronic hypertension because this is chronic whereas the hypotension is acute. Last is the patient with an expected blood pressure (110/64). Question 16 of 20 Report content error 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 The patient does not have shock as this was sudden and a one-time event. Other factors would need to be assessed over time (e.g., blood pressure continues to fall) to determine shock. Correct Postural hypotension The patient has orthostatic, or postural, hypotension since this event of hypotension occurred when moving from a supine to a sitting position. Hypertension stage 1 The patient’s blood pressure does not indicate hypertension, which is abnormally elevated blood pressure. Hypotension The patient does not have hypotension as this was sudden and a one-time event. Other factors would need to be assessed over time (e.g., blood pressure continues to fall) to determine hypotension. Question 17 of 20 Report content error Which actions would the nurse take for a patient with low blood pressure from decreased peripheral vascular resistance? Administer prescribed antihypertensive medications. Antihypertensive medications are for treatment of hypertension, not for low blood pressure; in fact, this would make the situation worse. Correct Administer prescribed intravenous (IV) fluids. Fluids are needed to increase the low blood pressure. Correct Administer prescribed oxygen. Oxygen is needed to supply extra oxygen to the body during hypotension. Correct Position supine with legs elevated. This position increases blood back to the heart. Position prone with head on small pillow. Positioning in the prone position with the head on a small pillow will not improve low blood pressure. Question 18 of 20 Report content error 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? Correct Age The patient is an older adult, which increases the chance for hypertension. Obesity Although obesity does increase the chance of hypertension, the patient is not obese at 5’4”, 100 lb (45.4 kg). Alcohol use Although alcohol can increase the chance of hypertension, the patient’s alcohol intake is within the acceptable guidelines of one drink per day for women. Salt intake Although salt can increase the chance of hypertension, the patient limits salt in her diet, thereby decreasing the chance of hypertension. Question 19 of 20 Report content error Which finding would alert the nurse that a patient with a blood pressure of 80/40 is improving? Correct Skin becomes warm and dry. The patient has hypotension (80/40); if the skin becomes warm and dry, the patient is improving because the skin is not cool and clammy. Blood pressure decreases. If blood pressure decreases, the patient with hypotension is declining, not improving. DASH diet is consumed. A DASH (Dietary Approaches to Stop Hypertension) diet is consumed for hypertension, not hypotension. Stress level decreases. A decreasing stress level indicates a patient with hypertension (not hypotension) is improving. Question 20 of 20 Report content error Which actions would the nurse take for a patient with the following blood pressures: 119/74, 125/78, 130/83, and 135/88? Correct Measure oxygen saturation level. The nurse would measure oxygen saturation levels because the patient is exhibiting an upward trend of the blood pressure. Monitor blood pressure every 4 hours. With a steady upward trend, blood pressure needs to be monitored more often than every 4 hours. Correct Reassess the circulatory system. The nurse would reassess the circulatory system (not just the vital signs) because the patient is exhibiting an upward trend of the blood pressure. Correct Perform a head-to-toe assessment. The nurse would perform a head-to-toe assessment because the patient is exhibiting an upward trend of the blood pressure. Correct Notify health care provider. The nurse would notify the health care provider because the patient is exhibiting an upward trend of the blood pressure. NSG 522 Clinical I Chapter 29, Vital Signs Blood Pressure Quizlet
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