ATI RN
ATI Nurs 112 Fundamentals of Nursing Exam Questions
Extract:
Question 1 of 5
The nursing assistant informs the nurse that the patient's blood pressure is 220/102 using the electronic monitor. What is the priority action of the nurse?
Correct Answer: C
Rationale: The correct answer is C: Take the patient's blood pressure manually with a sphygmomanometer and stethoscope. This is the priority action because the electronic monitor reading of 220/102 is considered extremely high and may be inaccurate. By manually measuring the blood pressure, the nurse can confirm the accuracy of the reading and determine the appropriate course of action.
Choice A is incorrect because obtaining an order for antihypertensive medications should not be the immediate action without confirming the accuracy of the reading.
Choice B is incorrect because rechecking the blood pressure with the electronic monitor may not provide accurate results.
Choice D is incorrect as performing a neurological assessment is not the priority action when dealing with a high blood pressure reading.
Question 2 of 5
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Question 3 of 5
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Question 4 of 5
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Question 5 of 5
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