The clinic nurse measures the client's blood pressure and obtains ...

[Tazate]

The clinic nurse measures the client's blood pressure and obtains a reading of 144/82. The client's baseline blood pressure has been normal. For what factors would the nurse assess the client based on the current blood pressure reading?
 
  1. Diet
  2. Medication history
  3. Activity
  4. History of recent symptoms of hypertension
  5. Recent stress factors the client has experienced

Question 2

Which factors could influence oxygen saturation measurement? Select all that apply.
 
  1. Hemoglobin
  2. Hematocrit
  3. Carbon dioxide poisoning
  4. Activity
  5. Circulation

[adf223]

Answer to Question 1

Correct Answer: 1,2,3,5

The client's diet should be assessed because foods high in sodium could elevate the systolic pressure mildly. The nurse should also assess the client's medication history and activity, as these can impact blood pressure. There is not likely to be a history of symptoms of hypertension, because borderline hypertension usually does not cause symptoms. The client's exposure to stress such as financial pressures and family issues can cause an elevation in systolic pressure.

Answer to Question 2

Correct Answer: 1,4,5

Hemoglobin is required to carry oxygen. A client who is severely anemic might have hemoglobin that is fully saturated with oxygen but inadequate oxygen to supply the tissues, yet the pulse oximeter will return a normal value. Hematocrit values have no impact on oximeter readings. Carbon monoxide, not dioxide, poisoning will yield false measurements because the oximeter cannot discriminate between hemoglobin saturated with carbon monoxide versus oxygen. Shivering or excessive movement of the oximeter sensor site will interfere with accurate readings. The oximeter will not return an accurate reading if the sensor is placed in an area with reduced circulation.

[Tazate]

Thank you

[adf223]

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