91. Maria, a 17-year-old pregnant has a blood pressure reported

91. Maria, a 17-year-old pregnant has a blood pressure reported to be very high. What is the most appropriate nursing action to take? a. Take it again in 20 minutes. b. Call the doctor. c. Measure the cuff width to the Maria’s arm. d. Prepare to give an antihypertensive. 92. A child with tetralogy of Fallot has been admitted. What equipment is most important to have at the bedside? a. Morphine b. A blood pressure cuff. c. A thermometer d. An oxygen setup 93. An 18-month-old presents with nasal flaring, intercostals and substernal retractions, and a respiratory rate of 50. What is the most appropriate nursing diagnosis? a. Knowledge deficit. b. Ineffective breathing pattern. c. Ineffective d. High risk for altered body temperature

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