A client with a history of hypertension is admitted with a severe headache and blurred vision. Which of the following findings would indicate a hypertensive crisis?

Blood pressure of 180/120 mmHg.

Heart rate of 90 beats per minute.

Respiratory rate of 20 breaths per minute.

Temperature of 37°C (98.6°F).

Answer and Explanation

The Correct Answer is A

Choice A rationale
A blood pressure reading of 180/120 mmHg or higher is indicative of a hypertensive crisis. This condition requires immediate medical attention to prevent damage to vital organs such as the heart, kidneys, and brain.
Choice B rationale
A heart rate of 90 beats per minute is within the normal range and does not indicate a hypertensive crisis. While it is important to monitor heart rate, it is not a definitive sign of a hypertensive emergency.
Choice C rationale
A respiratory rate of 20 breaths per minute is within the normal range and does not indicate a hypertensive crisis. Respiratory rate alone is not a reliable indicator of hypertensive emergencies.
Choice D rationale
A temperature of 37°C (98.6°F) is normal and does not indicate a hypertensive crisis. Body temperature is not a primary indicator of hypertensive emergencies.

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Correct Answer is A

Explanation

Choice A rationale
It takes about 14 days to develop antibodies and immunity to the disease after vaccine administration. This is why the patient is asked to return in 2 to 3 weeks for an antibody titer. The immune system needs time to respond to the vaccine and produce detectable levels of antibodies.
Choice B rationale
The laboratory running out of blood specimen tubes is not a valid reason for delaying the antibody titer. This choice does not provide an accurate explanation for the patient.
Choice C rationale
It takes about 14 days to develop antibodies, not antigens, and immunity to the disease after vaccine administration. This choice contains incorrect information about the immune response.
Choice D rationale
After receiving the vaccine, the patient is not likely to transmit the communicable disease to the laboratory. This choice does not provide a valid reason for delaying the antibody titer.

A. Administering supplemental oxygen. B. Encouraging the client to use an incentive spirometer. C. Administering a bronchodilator as prescribed. D. Positioning the client in high Fowler’s position.

Correct Answer is A

Explanation

Choice A rationale
Administering supplemental oxygen is the priority intervention for a client with COPD who has an oxygen saturation of 88% on room air. This low oxygen saturation indicates hypoxemia, which requires immediate correction to prevent further respiratory distress.
Choice B rationale
Encouraging the client to use an incentive spirometer is important for lung expansion and preventing atelectasis, but it is not the priority intervention in this scenario. The immediate concern is to correct the hypoxemia.
Choice C rationale
Administering a bronchodilator as prescribed is important for managing COPD symptoms, but the priority intervention is to correct the hypoxemia by administering supplemental oxygen.
Choice D rationale
Positioning the client in high Fowler’s position can help improve breathing, but the priority intervention is to correct the hypoxemia by administering supplemental oxygen.

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A client with a history of hypertension is admitted with a severe headache and blurred vision. Which of the following findings would indicate a hypertensive crisis?

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Naxlex Comprehensive Predictor Exams

After receiving a vaccination for a communicable disease, the patient was asked to return in 2 to 3 weeks to get an antibody titer and asks why blood testing can’t be done immediately.How should the RN (registered nurse) respond?

Correct Answer is A

Explanation

A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with increased shortness of breath and a productive cough. The nurse notes the client’s oxygen saturation is 88% on room air. Which of the following interventions should the nurse implement first?

Correct Answer is A

Explanation

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