A client presents to the emergency department complaining of headaches and blurred vision. The client's vital signs are as follows, Pulse 102 beats/minute, BP 172/92. RR 20 breaths/minute, SpO2.97% on room air temperature of 98.64. Which of the following interventions would be most appropriate for this patient?

Administer IV hydralazine and monitor blood pressure

Administer oxygen at 10 liters/minute by non rebreather mask

Administer acetaminophen 650 mg PO re-check temperature

Infuse 0.9% sodium chioride at 120 mL/hour

Answer and Explanation

The Correct Answer is A

A) "Administer IV hydralazine and monitor blood pressure":
. The patient's elevated blood pressure (172/92 mmHg), along with headaches and blurred vision, could indicate a hypertensive emergency, a serious condition where extremely high blood pressure can cause acute organ damage. Hydralazine is a common intravenous antihypertensive medication used to lower blood pressure quickly in these situations. The nurse should administer hydralazine as prescribed and closely monitor the blood pressure to prevent complications like stroke, heart failure, or kidney damage. Blood pressure management is the priority, as the patient's symptoms are likely related to the elevated BP.

B) "Administer oxygen at 10 liters/minute by non-rebreather mask":
. While oxygen therapy may be appropriate for patients with respiratory distress or hypoxia, the patient's SpO2 is 97% on room air, indicating that there is no immediate oxygenation issue. Administering oxygen unnecessarily could lead to oxygen toxicity, and it is not the priority in this case. The patient's main concern is their elevated blood pressure, which requires urgent management.

C) "Administer acetaminophen 650 mg PO re-check temperature":
. While headaches are one of the patient's complaints, there is no indication of fever (the temperature is 98.6°F). Administering acetaminophen would be appropriate for pain relief, but it is not the priority in this case. The elevated blood pressure and potential hypertensive emergency are the primary issues that need to be addressed first.

D) "Infuse 0.9% sodium chloride at 120 mL/hour":
. Normal saline (0.9% sodium chloride) is typically used for hydration, but there is no indication that the patient is dehydrated or that intravenous fluids are the priority. In cases of hypertensive emergency, the goal is to lower blood pressure using antihypertensive medications, not to infuse fluids. Fluid administration could potentially worsen the situation if the elevated blood pressure is not addressed first.

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Correct Answer is ["44"]

Explanation

Total volume to infuse: 400 mL

Infusion time: 3 hours

Drop factor of tubing: 20 gtt/mL

To find:

Drip rate (gtt/min)

Step 1: Convert infusion time to minutes

3 hours x 60 minutes/hour = 180 minutes

Step 2: Calculate the total number of drops

Total drops = Total volume x Drop factor

Total drops = 400 mL x 20 gtt/mL = 8000 gtt

Step 3: Calculate the drip rate

Drip rate = Total drops / Infusion time in minutes

Drip rate = 8000 gtt / 180 minutes = 44.44 gtt/min

Step 4: Round to the nearest whole number

44 gtt/min

A. Instruct the patient to swallow the medication with the head tilted backwards B. Place the medication in the backwards in the back of the mouth on the affected side C. Evaluate the patient’s ability to swallow D. Provide the patient with thickened liquids

Correct Answer is C

Explanation

A) Instruct the patient to swallow the medication with the head tilted backwards:
Tilting the head backward while swallowing may worsen the patient's ability to swallow, especially if they are experiencing facial droop and slurred speech. This position could increase the risk of aspiration or choking. A safer approach involves evaluating the patient’s swallowing ability before giving any oral medications.

B) Place the medication in the back of the mouth on the affected side:
While placing the medication on the unaffected side might seem like an alternative to help with swallowing, it is still important to assess the patient's swallowing ability first. If the patient has difficulty swallowing due to neurological deficits, placing the medication on the affected side could increase the risk of aspiration, leading to complications such as pneumonia.

C) Evaluate the patient’s ability to swallow:
Evaluating the patient's ability to swallow is the most important initial action. Facial droop and slurred speech can indicate potential dysphagia or difficulty swallowing, which could lead to aspiration if medications are given orally without further assessment. The nurse must determine if the patient can swallow safely before administering any oral medications, including aspirin, to prevent complications.

D) Provide the patient with thickened liquids:
Thickened liquids may be helpful for patients with known dysphagia, but this approach is not suitable in this case because the first priority is assessing the patient's swallowing ability. Giving thickened liquids without evaluating swallowing could increase the risk of aspiration if the patient is unable to manage liquids safely. An evaluation should precede any interventions like thickening liquids.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["44"]

Explanation

The nurse is caring for a client in the emergency department who is experiencing facial droop and slurred speech orally. The physician ordered aspirin to be given orally. What should the nurse do?

Correct Answer is C

Explanation

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