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 D

Explanation

(A) “I promise I won’t tell anyone about this.”: This statement is inappropriate because it is the nurse’s legal and ethical duty to report any suspicion or evidence of child abuse to the appropriate authorities. Keeping the information confidential could potentially endanger the child.

(B) “Let’s discuss what you have told me with your family members.”: This statement could potentially put the child at further risk, especially if the abuser is a family member. The child’s safety is the primary concern, and discussing the abuse with family members without the involvement of child protective services could be harmful.

(c) “Your family is bad for doing this to you.”: This statement is judgmental and unprofessional. It’s important to maintain a neutral stance and focus on the child’s feelings and safety rather than placing blame.

(D) “It is not your fault that this happened.”: This is the most appropriate response. It’s crucial to reassure the child that they are not to blame for the abuse. This can help alleviate feelings of guilt or shame that the child may be experiencing. The nurse should also take steps to ensure the child’s immediate safety and report the abuse to the appropriate authorities.

A. Atropine B. Verapamil C. Digoxin D. Carvedilol

Correct Answer is A

Explanation

A) Atropine:
Atropine is a medication used to increase heart rate. It acts by blocking the parasympathetic nervous system, leading to increased heart rate. It is commonly used to treat bradycardia, which is characterized by a heart rate less than 60 beats per minute. In this scenario, with the client's apical heart rate at 49/min, indicating bradycardia, the nurse should prepare to administer atropine to increase the heart rate.

B) Verapamil:
Verapamil is a calcium channel blocker that can decrease heart rate. It is used to treat various cardiac conditions, but it is not appropriate for a client with bradycardia, as it would further lower the heart rate.

C) Digoxin:
Digoxin is a medication used to treat heart failure and certain arrhythmias, but it does not directly increase heart rate. In fact, it can exacerbate bradycardia in some cases.

D) Carvedilol:
Carvedilol is a beta-blocker that can decrease heart rate. It is used to treat hypertension, heart failure, and other cardiovascular conditions, but it is not appropriate for a client with bradycardia, as it would further lower the heart rate.

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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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