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NCLEX · Immunizations and Health Screening

A client has a blood pressure reading of 138/88 mmHg. How should the LPN classify this finding?

Reviewed by Jordan Morley, Editorial Lead at 247SimpleTests. Written by the 247SimpleTests Editorial Team from the official source material cited on every question.

Correct answer

Elevated (previously 'prehypertension') — systolic 120-129 and diastolic <80; or Stage 1 hypertension — systolic 130-139 OR diastolic 80-89

  1. A Stage 2 hypertension
  2. B Normal
  3. C Hypertensive crisis
  4. D Elevated (previously 'prehypertension') — systolic 120-129 and diastolic <80; or Stage 1 hypertension — systolic 130-139 OR diastolic 80-89

Why this is the answer

Acc/aha 2017 blood pressure categories: Normal: <120/<80; Elevated: 120-129/<80; Stage 1 HTN: 130-139 OR 80-89; Stage 2 HTN: ≥140 OR ≥90; Hypertensive Crisis: >180/>120. 138/88 = Stage 1 hypertension (systolic 130-139, diastolic 80-89).

Nursing implications: Report to RN/provider; reinforce lifestyle modifications (DASH diet, sodium restriction <2.3g/day, 150 min/week moderate exercise, weight loss, smoking cessation, alcohol moderation); medication may be initiated depending on cardiovascular risk; repeat measurements to confirm; document. Stage 1 HTN with low cardiovascular risk may be managed with lifestyle changes alone initially.

Source: NCLEX-PN HP — Cardiovascular Prevention, Blood Pressure Classification

Practice more questions

This question is from our NCLEX Practice Tests practice test. Take the full practice test to test your knowledge across all Immunizations and Health Screening and other topics.

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About this topic: Immunizations and Health Screening

Immunizations and health screening questions cover the childhood and adult vaccine schedules, contraindications, and the recommended screenings — blood pressure, cholesterol, cancer screening — by age and risk. This is one of 14 PN: Health Promotion and Maintenance questions on immunizations and health screening, each with a full explanation on a single study page.

New to this exam? Our NCLEX exam guide explains the format, scoring, and how to prepare.

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