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 D
Explanation
(A) Increase the heat in the client’s room: Increasing the heat in the client’s room is not typically recommended for a client experiencing dyspnea. Heat can sometimes make breathing more difficult, and it does not address the underlying cause of the dyspnea.
(B) Perform nasotracheal suctioning for the client: Nasotracheal suctioning can be used to clear the airway in certain situations, but it is not typically the first-line treatment for dyspnea in a client at the end of life. It can be uncomfortable and distressing for the client.
(C) Place the head of the client’s bed flat: Placing the head of the bed flat can actually make breathing more difficult for a client experiencing dyspnea. It is generally more helpful to elevate the head of the bed to facilitate easier breathing.
(D) Administer an opioid narcotic to the client: This is the most appropriate answer. Opioid narcotics can help to relieve dyspnea in clients at the end of life by reducing anxiety, decreasing the sensation of breathlessness, and improving the client’s overall comfort level. The use of opioids in this context should be carefully monitored to manage potential side effects.
Correct Answer is ["B","D"]
Explanation
A. Positive Kernig's sign:
Positive Kernig's sign is associated with meningitis, not thrombosis. It is a clinical sign where pain is elicited when the hip is flexed at a 90-degree angle and then the knee is extended. This sign is not relevant for identifying a thrombus.
B. Dull, aching calf pain:
Dull, aching calf pain is a common symptom of deep vein thrombosis (DVT). Pain, swelling, and tenderness in the calf are typical manifestations of a thrombus in the leg veins. This symptom should alert the nurse to the possibility of a thrombus.
C. Soft, pliable calf muscle:
A soft, pliable calf muscle is not indicative of a thrombus. In the case of DVT, the affected leg is usually swollen, firm, and tender. Thus, this manifestation does not suggest the presence of a thrombus.
D. Positive Homan's sign:
Positive Homan's sign is identified when there is pain in the calf upon dorsiflexion of the foot. This sign can be indicative of DVT. Although not highly specific or sensitive, it is one of the traditional signs used to assess for the presence of a thrombus in the leg.
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