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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is ["B","C","D"]

Explanation

A) "If a client refuses a medication, you can place it in your pocket to administer later."
This statement is incorrect. Placing a medication in the pocket for later administration is not an appropriate practice and can lead to unauthorized possession and potential diversion of controlled substances. However, the second part of the statement, "You are required to have a second nurse witness disposal of a controlled substance," is correct.

B) "We use an automated dispensing device to track the use of controlled substances."
Automated dispensing devices are commonly used to track the administration and removal of controlled substances. This helps to ensure accountability and prevents diversion.

C) "Activities of the automated dispensing machine will be reviewed periodically."
Regular review of the activities of the automated dispensing machine helps to monitor for any discrepancies or irregularities in the handling of controlled substances, thus enhancing safety measures.

D) "We count the amount of a controlled substance available before removal from a medication drawer."
Counting the amount of controlled substance available before removal from a medication drawer is a crucial step in ensuring accurate inventory management and preventing unauthorized removal or diversion.

A. Evaluating the collected data B. Searching for credible sources C. Implementing recommendations D. Identifying a problem

Correct Answer is B

Explanation

(A) Evaluating the collected data: This step involves analyzing the data that has been collected during the research process. However, in this scenario, the nurse is in the process of researching data, which suggests that the data collection phase is still ongoing.

(B) Searching for credible sources: This is the most appropriate answer. The nurse is in the process of researching data about best practices for reducing medication errors. This indicates that the nurse is currently searching for credible sources of information, which is a crucial step in the EBP process.

(C) Implementing recommendations: This step involves applying the findings from the research to practice. However, in this scenario, the nurse is still in the research phase, so implementation has not yet occurred.

(D) Identifying a problem: While identifying a problem is an important step in the EBP process, in this scenario, the problem (medication errors on a surgical unit) has already been identified. The nurse is now in the process of researching data, which suggests that the problem identification step has already been completed.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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