A nurse is administering an IV antihypertensive to a client who has a BP of 185/130 mm Hg. Which of the following actions should the nurse take first?
Check for orthostatic hypertension.
Instruct the client to restrict sodium intake.
Assist the client to make lifestyle changes.
Monitor the client's BP every 5 minutes.
The Correct Answer is D
A. Check for orthostatic hypertension: While checking for orthostatic hypertension is important; it is not the first action a nurse should take when administering an IV antihypertensive. The priority is to monitor the client’s response to the medication.
B. Instruct the client to restrict sodium intake: While dietary modifications such as sodium restriction can help manage hypertension, it is not the immediate concern when administering an IV antihypertensive. The priority is to monitor the client’s response to the medication.
C. Assist the client to make lifestyle changes: Lifestyle changes are a crucial part of managing hypertension, but they are not the immediate concern when administering an IV antihypertensive. The priority is to monitor the client’s response to the medication.
D. Monitor the client’s BP every 5 minutes: This is the correct answer. When administering an IV antihypertensive, it is crucial to closely monitor the client’s blood pressure to assess the effectiveness of the medication and to ensure the client’s safety. The client’s high blood pressure of 185/130 mm Hg is a serious condition that requires immediate and careful management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Recent oral intake: This information is crucial because pyridostigmine is typically administered orally and can interact with food, affecting its absorption. Ensuring that the client has recently eaten or will eat soon is essential to minimize gastrointestinal side effects and optimize medication absorption.
B) Trouble sleeping: While sleep disturbances can be a concern, particularly if they worsen with medication use, they may not be the most critical information to obtain before administering pyridostigmine. However, if the client experiences worsening sleep disturbances after starting the medication, it should be reported to the healthcare provider.
C) Unexplained weight loss: While weight loss can be a symptom of myasthenia gravis, it may not be directly related to the administration of pyridostigmine. However, if the client experiences significant weight loss or other unexplained symptoms, further assessment and evaluation may be necessary.
D) Difficulty with urination: Pyridostigmine can affect bladder function and may exacerbate urinary retention, especially in clients with myasthenia gravis. However, obtaining information about the client's recent oral intake is more crucial to ensure optimal medication absorption and minimize gastrointestinal side effects. Difficulty with urination should still be monitored, but it may not be the most immediate concern before administering the medication.
Correct Answer is D
Explanation
A. A 14-month-old toddler with bruises on bony prominences:
Bruises on bony prominences are common in toddlers who are learning to walk and are prone to falls. While bruising can raise concerns, it is not necessarily indicative of physical abuse, especially in this age group.
B. A 9-month-old infant who sustained near drowning:
Near drowning in an infant who climbed into the tub and turned on the water suggests an accidental event rather than physical abuse. This scenario is consistent with lack of supervision or an unfortunate accident.
C. A 3-year-old toddler with scalding burns:
Scalding burns from spilling hot tea on oneself can occur accidentally, especially in young children who may not understand the dangers associated with hot liquids. While the circumstances may raise suspicion, it does not necessarily indicate physical abuse without further evidence.
D. A 6-year-old child with a spiral fracture:
A spiral fracture of the tibia and fibula is concerning for physical abuse, especially in a child who reportedly sustained the injury while riding a bicycle. Spiral fractures are often associated with twisting or pulling forces and are considered suspicious for non-accidental trauma, particularly when there is no plausible explanation for the injury.
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