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 D

Explanation

A. "The client may benefit from a neurology consult." This statement is more appropriate for the recommendation component of SBAR. The background should focus on what has already occurred or is known, not what the nurse thinks should be done next.

B. "The client is disoriented and pupils are slow to respond to light." This would be part of the assessment component of SBAR, which describes the nurse's evaluation of the current condition.

C. "The client has developed drooping facial features." This statement can be included in theSituationcomponent because it describes the immediate concern that prompted the communication.

D. "The client has a history of hypertension." This statement is suitable for theBackgroundcomponent. It provides relevant medical history that helps the provider understand the context of the current situation.

A. Check the client's distal pulses in both legs. B. Keep the client overnight. C. Restrict the client's oral fluids. D. Keep the client on bed rest for 12 hr.

Correct Answer is A

Explanation

A. Check the client's distal pulses in both legs. It is important to assess distal pulses to ensure adequate circulation and to detect any signs of potential complications, such as arterial occlusion or hematoma formation, after cardiac catheterization.

B. Keep the client overnight. Most clients do not need to be kept overnight after cardiac catheterization unless there are complications. This option is unnecessary in routine cases.

C. Restrict the client's oral fluids. Clients are encouraged to increase oral fluids after the procedure to help flush out the contrast dye used during the catheterization and reduce the risk of kidney damage.

D. Keep the client on bed rest for 12 hr. Bed rest is required for a few hours (typically 4-6 hours) after cardiac catheterization to reduce the risk of bleeding from the puncture site. However, 12 hours of bed rest is generally not necessary unless there are specific complications.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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