A nurse is administering nicardipine to a client who has a BP of 180/120 mm Hg. Which of the following actions should the nurse take first?

Check for orthostatic hypertension.

Assist the client to make lifestyle changes.

Instruct the client to restrict sodium intake.

Monitor the client's BP every 5 minutes.

Answer and Explanation

The Correct Answer is D

A. Check for orthostatic hypotension. While important, checking for orthostatic hypotension is not the priority action in a hypertensive emergency, where rapid blood pressure reduction is necessary.

B. Assist the client to make lifestyle changes. Assisting the client with lifestyle changes is part of long-term blood pressure management but is not a priority action when administering nicardipine for acute hypertension.

C. Instruct the client to restrict sodium intake. Sodium restriction is a key component of managing hypertension but is not the priority action during an acute hypertensive crisis.

D. Monitor the client's BP every 5 minutes. In a hypertensive crisis, frequent monitoring of the client’s blood pressure is essential to ensure the medication is lowering blood pressure safely and effectively.

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Correct Answer is B

Explanation

A. Liver: Liver is high in cholesterol and should be avoided by clients on a low-cholesterol diet. This is not a suitable choice for the client.

B. Beans: Beans are a high-fiber, plant-based protein source that is low in cholesterol. This is a good choice for a low-cholesterol diet.

C. Eggs: Eggs contain cholesterol, particularly in the yolk. While one egg a day may be acceptable for some individuals, this is generally a food that should be limited on a low-cholesterol diet.

D. Milk: Depending on the fat content, milk can be high in cholesterol. Clients should opt for skim or low-fat milk to reduce cholesterol intake. Full-fat milk is not ideal for a low-cholesterol diet.

A. Atrial gallop B. Ventricular gallop C. Closing of semilunar valves D. Closing of the atrioventricular valves

Correct Answer is B

Explanation

A. Atrial gallop: An atrial gallop is associated with the S4 heart sound, which occurs before the S1 sound due to the atrial contraction.

B. Ventricular gallop: An S3 heart sound is known as a ventricular gallop and is often a sign of heart failure or fluid overload. It occurs during early diastole when the ventricle fills rapidly.

C. Closing of semilunar valves: The closing of the semilunar valves (aortic and pulmonary) produces the S2 heart sound, not the S3 sound.

D. Closing of the atrioventricular valves: The closing of the atrioventricular valves (mitral and tricuspid) produces the S1 heart sound, not the S3 sound.

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A nurse is administering nicardipine to a client who has a BP of 180/120 mm Hg. Which of the following actions should the nurse take first?

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