a patient is diagnosed with essential hypertension which of the following blood pressures would you expect to see in this patient prior to taking medi

NCLEX-RN

NCLEX RN Actual Exam Test Bank

1. A patient is diagnosed with essential hypertension. Which of the following blood pressures would you expect to see in this patient prior to taking medications for the condition?

A. 142/92
B. 118/72
C. 120/80
D. 138/88

Correct answer: A

Rationale: Before starting medications for essential hypertension, a patient would typically present with a blood pressure reading equal to or greater than 140/90. This indicates high blood pressure and is characteristic of essential hypertension. Choice A, 142/92, falls within this range, making it the correct answer. Choices B (118/72), C (120/80), and D (138/88) all have blood pressure readings that are within the normal range and would not typically be expected in a patient diagnosed with essential hypertension. Therefore, choices B, C, and D are incorrect as they do not align with the elevated blood pressure levels seen in essential hypertension.

2. Why should a palpated pressure be performed before auscultating blood pressure?

A. To more clearly hear the Korotkoff sounds.
B. To detect the presence of an auscultatory gap.
C. To avoid missing a falsely elevated blood pressure.
D. To more readily identify phase IV of the Korotkoff sounds.

Correct answer: B

Rationale: Performing a palpated pressure before auscultating blood pressure helps in detecting the presence of an auscultatory gap. An auscultatory gap is a period during blood pressure measurement when Korotkoff sounds temporarily disappear before reappearing. Inflation of the cuff 20 to 30 mm Hg beyond the point where a palpated pulse disappears helps in identifying this gap. This technique ensures accurate blood pressure measurement by preventing the underestimation of blood pressure values. The other options are incorrect because palpating the pressure is not primarily done to hear Korotkoff sounds more clearly, avoid missing falsely elevated blood pressure, or readily identify a specific phase of Korotkoff sounds.

3. A 4-month-old child is at the clinic for a well-baby checkup and immunizations. Which of these actions is most appropriate when the nurse is assessing an infant's vital signs?

A. The infant's radial pulse should be palpated, and the nurse should notice any fluctuations resulting from activity or exercise.
B. The nurse should auscultate an apical rate for 1 minute and then assess for any normal irregularities, such as sinus dysrhythmia.
C. The infant's blood pressure should be assessed by using a stethoscope with a large diaphragm piece to hear the soft muffled Korotkoff sounds.
D. The infant's chest should be observed and the respiratory rate counted for 1 minute; the respiratory pattern may vary significantly.

Correct answer: B

Rationale: The nurse auscultates an apical rate, not a radial pulse, with infants and toddlers. The pulse should be counted by listening to the heart for 1 full minute to account for normal irregularities, such as sinus dysrhythmia. Children younger than 3 years of age have such small arm vessels; consequently, hearing Korotkoff sounds with a stethoscope is difficult. The nurse should use either an electronic blood pressure device that uses oscillometry or a Doppler ultrasound device to amplify the sounds. An infant's respiratory rate should be assessed by observing the infant's abdomen, not chest, because an infant's respirations are normally more diaphragmatic than thoracic. The nurse should auscultate an apical heart rate, not palpate a radial pulse, with infants and toddlers.

4. Which of the following is an example of client handling equipment?

A. Wheelchair
B. Height-adjustable bed
C. Shower chair
D. Call light

Correct answer: B

Rationale: Client handling equipment is designed to reduce stress and workload on healthcare professionals who assist, turn, or lift clients, aiming to decrease the risk of injuries from improper lifting techniques. A height-adjustable bed is a prime example of client handling equipment as it allows healthcare providers to raise the client to a suitable working height, facilitating care provision. Choices A, C, and D are not examples of client handling equipment. While a wheelchair, shower chair, and call light are essential in client care settings, they are not intended to aid in handling and lifting clients.

5. One of your patients is dependent on a mechanical ventilator for their respiratory needs. The patient cannot breathe on their own. Suddenly, the lights in the patient's room and the entire nursing unit go off. You realize that the electric power has been lost. What is the first thing that you should do for this patient?

A. Plug the ventilator into the red outlet in the room.
B. Plug the ventilator into the blue outlet in the room.
C. Use an Ambu bag to ventilate the patient.
D. Call the doctor about this emergency.

Correct answer: B

Rationale: In healthcare facilities, emergency generators are in place in case of power outages. The red outlets in patient rooms are connected to the emergency generator and provide power during such situations. By plugging the ventilator into the red outlet, you ensure that the patient's mechanical ventilation needs are met despite the power loss. Using an Ambu bag or calling the doctor should be secondary actions after ensuring the ventilator is powered correctly. Plugging the ventilator into the blue outlet is incorrect and can result in the ventilator not functioning during a power outage.