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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Correct Answer is B

Explanation

A. Increase in postoperative pain: Preoperative teaching typically includes information about pain management strategies, which should help to reduce, not increase, postoperative pain.

B. Reduced postoperative anxiety: This is correct. One of the key benefits of preoperative education is reduced anxiety. By understanding what to expect before, during, and after surgery, patients are often less anxious about the procedure.

C. Reduced postoperative respiratory function: Preoperative teaching usually includes instructions on deep breathing and coughing exercises to help prevent respiratory complications after surgery. Therefore, it should improve, not reduce, postoperative respiratory function.

D. Increased length of postoperative care in the health care facility: Preoperative education has been shown to reduce the length of hospital stay. By better understanding their surgery and postoperative care, patients are often able to recover more quickly and leave the hospital sooner

A. An adolescent who asks to stay in the hospital because he likes the room B. A toddler who has multiple bruises on the shins of both legs and his parents report that he is clumsy C. A school-age child who cries when the nurse is giving him an injection D. A preschooler who has a BMI indicating obesity

Correct Answer is A

Explanation

Answer: A. An adolescent who asks to stay in the hospital because he likes the room

Rationale:

A) An adolescent who asks to stay in the hospital because he likes the room: This finding may indicate that the adolescent is experiencing abuse or neglect at home. A desire to remain in the hospital could suggest that the child views it as a safe space compared to their home environment, warranting further assessment for possible abuse.

B) A toddler who has multiple bruises on the shins of both legs and his parents report that he is clumsy: Bruising on the shins is common in toddlers due to normal exploratory behavior and frequent falls. The parent's explanation aligns with developmental norms, making this finding less indicative of abuse.

C) A school-age child who cries when the nurse is giving him an injection: Crying during injections is a typical reaction for school-age children and does not suggest abuse. Emotional responses to medical procedures are age-appropriate and expected.

D) A preschooler who has a BMI indicating obesity: While obesity in children may raise concerns about diet and lifestyle, it is not inherently indicative of abuse. Further evaluation may be needed for nutritional and health interventions but does not typically suggest maltreatment.

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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?

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