Ncsbn- Post Test A-L 19 Correctly Answered Questions Latest Update

A client states, "I feel funny." The nurse uses electronic equipment to obtain vital signs and notes these findings: blood pressure 100/56 mm Hg, pulse 38, respirations 26. The client's previous reading: blood pressure 130/88 mm Hg, pulse 82, respirations 21. List the correct order of actions the nurse should now take (with 1 being the top priority). a. Assess for chest pain, dyspnea, low oxygen saturation, restlessness or other signs of respiratory or cardiac impairment b. Simultaneously check an apical and radial pulse manually c. Notify the health care provider d. Anticipate the need for ECG, oxygen administration, and emergency pacing {Ans: The sudden drop in both blood pressure and pulse indicate an acute cardiovascular event requiring rapid assessment and intervention to prevent cardiac arrest. At this point, the patient is not in crisis but needs a quick targeted assessment. Verify the bradycardia manually; perfusion may not occur with some arrhythmias, such as premature ventricular contractions, so checking the apical rate while palpating a distal pulse provides a quick assessment. Assessment for cardiovascular and respiratory instability is next. With all the assessment data in hand, it's time to contact the health care provider, anticipating the need for ECG,