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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Explanation
The sandbag should be placed over the left femoral artery insertion site where the catheter was inserted. This helps apply pressure to the site, reducing the risk of bleeding or hematoma formation by assisting with clot formation at the puncture site.
Correct Answer is D
Explanation
A. Expect to gain weight while taking this medication. Weight gain is not a common side effect of captopril (an ACE inhibitor). This is incorrect advice.
B. Expect insomnia while taking this medication. Insomnia is not a common side effect of captopril, so this advice is not appropriate.
C. Use salt substitutes while taking this medication. Salt substitutes often contain potassium, and ACE inhibitors like captopril can cause hyperkalemia (high potassium levels). Therefore, this advice is incorrect and potentially harmful.
D. Take the medication on an empty stomach. Captopril should be taken on an empty stomach, usually 1 hour before meals, to improve its absorption and efficacy.
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