The nurse is caring for a patient who complains of feeling light-headed and 'woozy.' The nurse checks the patient's pulse and finds that it is irregular. The patient's blood pressure is 100/72. It was 113/80 an hour earlier. What should the nurse do?

Correct Answer: A

Rationale: Light-headedness, irregular pulse, and BP drop (100/72 from 113/80) suggest arrhythmia or instability; calling the physician is urgent. Apical/radial delays action. Pressure or thumb won't clarify. Choice A is correct, per escalation protocol.

Correct Answer: B

Rationale: A patient hospitalized for high blood pressure requires vital signs every 4 hours to monitor hypertension's impact and treatment efficacy, per acute care protocols. Critical care patients need more frequent checks (e.g., hourly). Long-term care residents (C, D) typically have stable conditions, requiring less frequent monitoring unless specified. The answer key selects B, reflecting nursing prioritization of acute conditions like hypertension over chronic or critical states, ensuring timely intervention for potential complications.

Correct Answer: A

Rationale: Systolic pressure is the top number (140), measuring arterial pressure during heart contraction, per the answer key. Diastolic is the bottom (86), pulse pressure the difference, and hypotension a conditionnot terms for 140. Nurses document this per BP standards.

Correct Answer: D

Rationale: Inspection uses vision, hearing, and smell , per the answer key, to observe without tools. Stethoscopes are for auscultation, hands percussion, palpation touch. Nurses, per Taylor, rely on senses for initial assessment data.