A nurse in the ER is caring for a patient who had fallen at home. She reviews the blood pressure reading of 160/80 mm Hg. The client denies any history of hypertension. Which of the following actions should the nurse take first?
Ask the client if she is having pain
Request a prescription for an antianxiety medication
Request a prescription for an antihypertensive medication
Return in 30 min to recheck the client’s blood pressure
The Correct Answer is A
A. Ask the client if she is having pain.
This option recognizes the potential relationship between pain and elevated blood pressure. Assessing the client for pain is crucial, as pain can contribute to increased blood pressure.
B. Request a prescription for an antianxiety medication.
This option assumes that anxiety might be the cause of the elevated blood pressure. However, without further assessment, it may not be appropriate to jump to prescribing medication for anxiety.
C. Request a prescription for an antihypertensive medication.
Initiating antihypertensive medication without further assessment may not be the most appropriate first step, especially if the elevated blood pressure is related to pain or another temporary factor.
D. Return in 30 minutes to recheck the client’s blood pressure.
While monitoring blood pressure is important, waiting 30 minutes without further assessment or intervention might delay addressing the underlying issue, especially if it is related to pain or another acute problem.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","E"]
Explanation
A. Place the client in semi-Fowler’s position:
While the semi-Fowler's position can be helpful in assessing respiratory function, it is not specifically required for measuring the respiratory rate. The key is to ensure the client is comfortable and able to breathe easily.
B. Have the client rest an arm across the abdomen:
Placing the arm across the abdomen is not a standard practice for measuring respiratory rate. The key is to allow the client to breathe naturally, and this position is not necessary for accurate measurement.
C. Observe one full respiratory cycle before counting the rate:
This ensures that the count is accurate and reflective of the client's typical breathing pattern.
D. Count the rate for 30 seconds if it is irregular:
When measuring the respiratory rate, it is generally recommended to count for a full minute to obtain an accurate representation of the client's breathing pattern. Counting for 30 seconds may underestimate or overestimate the rate, especially if the irregularity is not consistent.
E. Count and report any sighs the client demonstrates:
Sighs can be indicative of emotional or physiological stress, and noting them is important for a comprehensive respiratory assessment.
Correct Answer is ["20"]
Explanation
To administer the ordered dose of furosemide (Lasix) 20mg, you need to calculate the amount of mL required from the available solution. The available solution has a concentration of 2 mg/2 mL, which means that for every 2 mL of solution, there are 2 mg of furosemide. To find the amount of mL needed to deliver 20 mg of furosemide, you can use the following formula:
mL = (ordered dose / available dose) x available volume
Plugging in the values, we get:
mL = (20 mg / 2 mg) x 2 mL
mL = 10 x 2 mL
mL = 20 mL
Therefore, you need to administer 20 mL of the available solution to give the patient 20 mg of furosemide.
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