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 C

Explanation

A. "I can drink wine in moderation." Moderate wine consumption (particularly red wine) is often considered acceptable as part of the Mediterranean diet. This statement does not indicate a need for further teaching.

B. "I will limit my intake of eggs." Eggs can be consumed in moderation on the Mediterranean diet, typically no more than a few times a week. This statement reflects an understanding of the diet and does not indicate a need for further teaching.

C. "I will limit my intake of red meat to two times per week." The Mediterranean diet recommends limiting red meat consumption, but typically to less than two times per week. This statement indicates a need for further teaching as it suggests a higher frequency than recommended.

D. "I should cook with olive oil." Olive oil is a key component of the Mediterranean diet, replacing butter and other fats. This statement reflects correct understanding and does not indicate a need for further teaching.

A. Reassuring the partner of a client who sustained a closed head injury B. Collecting data from a client who reports unilateral calf pain when ambulating C. Taking a telephone prescription for a client who is to be transferred from PACU D. Reinforcing a client's dressing on an above-the-knee amputation surgical site

Correct Answer is B

Explanation

A. Reassuring the partner of a client who sustained a closed head injury: While providing emotional support to family members is important, this is not the first priority. The immediate concern should be a potential physical complication in a client.

B. Collecting data from a client who reports unilateral calf pain when ambulating: Unilateral calf pain can indicate deep vein thrombosis (DVT), which can lead to a pulmonary embolism if left untreated. This is the most urgent situation and requires immediate assessment.

C. Taking a telephone prescription for a client who is to be transferred from PACU: While transferring a client requires coordination, it is not as urgent as assessing for potential life-threatening complications, such as DVT.

D. Reinforcing a client's dressing on an above-the-knee amputation surgical site: While it is important to manage the surgical site, the client with potential DVT requires more immediate attention due to the risk of pulmonary embolism.

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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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