Vital signs for a patient reveal a high blood pressure of 187/100 ...

[awywial]

Vital signs for a patient reveal a high blood pressure of 187/100 . Orders state to notify the health care provider for diastolic blood pressure greater than 90 . What is the nurse's first action?
 
  a. Assess the patient for other symptoms or problems, and then notify the health care provider.
  b. Review the most recent lab results for the patient's potassium level.
  c. Follow the clinical protocol for a stroke.
  d. Administer an antihypertensive medication from the stock supply, and then notify the health care provider.

Question 2

A 5-year-old boy is admitted for surgery to have his tonsils removed. Which of the following does the nurse plan to do on the basis of her knowledge about children of this age?
 
  a. Allow the child to take responsibility for his own preoperative hygienic care.
  b. Leave the child alone to relax before the procedure.
  c. Allow the child to handle and look at the equipment when the nurse takes his blood pressure.
  d. Provide magazines and puzzles for diversion.

[kishoreddi]

Answer to Question 1

A
The best answer is to briefly reassess the patient for other symptoms or problems, and then notify the health care provider according to the orders. Reviewing the potassium level does not address the problem of high blood pressure. The nurse does not make medical diagnoses, such as stroke. The nurse needs an order to administer medications.

Answer to Question 2

C

Feedback
A A preschool child is unable to take responsibility for his or her own preoperative hygienic care.
B Leaving the preschooler alone may increase the child's anxiety.
C Preschool children may cooperate if they are allowed to manipulate the equipment.
D Magazines and puzzles would be more appropriate activities for the older child. The preschool child likes to engage in pretend play by using the imagination and imitating adult behaviour.