Practice Quiz

CNOR Operating Room Nursing

Category - Preop

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The nurse is performing a preoperative assessment on a patient before a colon resection and notes the patient’s blood pressure is elevated to 142/90 mmHg. What should the nurse do next?
  1. Record the vital sign in the chart, allow the patient to rest quietly in a room, and recheck in 30 minutes.
  2. Lower the head of the bed and tell the patient they need to lie flat for the next hour.
  3. Notify the physician of the blood pressure result and consider rescheduling the surgery.
  4. Obtain an order for antihypertensive medications to keep the blood pressure under control.
Explanation
Answer: A-When checking a preoperative blood pressure and determining the level is elevated at 142/90 mmHg, the nurse should record the vital sign in the chart, allow the patient to rest quietly in a room, and recheck in 30 minutes. The patient could be anxious about the upcoming surgery or could have another condition manifesting as elevated blood pressure. The nurse should notify the physician but the surgery does not necessarily need to be rescheduled.
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