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 C
Explanation
Respiratory acidosis occurs when there is inadequate removal of carbon dioxide (PaCO2) by the lungs, leading to an increase in the partial pressure of carbon dioxide (hypercapnia) and a decrease in pH.
In this case, the pH is low (7.22), and the PaCO2 is elevated (68 mm Hg), indicating respiratory acidosis. The pH is below the normal range, suggesting acidemia.
The other ABG values (PaO2, oxygen saturation, and bicarbonate) are within or close to normal limits, which do not support the diagnosis of metabolic acidosis, respiratory alkalosis, or metabolic alkalosis.
Correct Answer is A
Explanation
A) Tingling of the lips:
This is the correct choice. Hypocalcemia, which is low calcium levels in the blood, can lead to neurological symptoms such as tingling sensations around the lips and in the extremities. This occurs due to the effect of low calcium levels on the nervous system.
B) Hypoactive bowel sounds:
Hypocalcemia primarily affects neuromuscular function rather than gastrointestinal function. While calcium imbalances can impact gastrointestinal motility, hypoactive bowel sounds are not typically associated with hypocalcemia.
C) Skeletal muscle weakness:
Skeletal muscle weakness is a common symptom of hypocalcemia. Low calcium levels affect the ability of muscles to contract effectively, leading to weakness and fatigue.
D) Decreased deep-tendon reflexes:
Hypocalcemia can actually lead to increased deep-tendon reflexes rather than decreased reflexes. Calcium plays a role in neuromuscular transmission, and low levels can result in hyperexcitability of nerves, leading to increased reflexes rather than decreased reflexes.
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