A nurse is assessing a client who is experiencing a hypertensive crisis. Which of the following manifestations should the nurse expect?

Skin cool to touch

Jugular vein distention

Headache

Weak peripheral pulses

Answer and Explanation

The Correct Answer is C

Rationale:

A. Skin cool to touch: Cool skin is more commonly associated with shock states or severe peripheral vasoconstriction, not with a hypertensive crisis. In hypertensive crisis, the client is more likely to have warm skin due to increased circulation from elevated blood pressure.

B. Jugular vein distention: While jugular vein distention can occur in right-sided heart failure or severe fluid overload, it is not a hallmark manifestation of hypertensive crisis. The acute issue in hypertensive crisis is extreme elevation in blood pressure with end-organ effects.

C. Headache: Severe headache is a common and classic symptom of hypertensive crisis due to sudden, extreme elevations in blood pressure causing increased ICP and cerebral vessel stress. It often signals an urgent need for BP control to prevent complications such as stroke.

D. Weak peripheral pulses: Weak pulses are more often associated with low cardiac output or severe arterial obstruction. In hypertensive crisis, peripheral pulses are typically bounding and strong because of the elevated systemic vascular resistance.

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Free Nursing Study Resources

Correct Answer is A

Explanation

Rationale:

A. Maintain the irrigation solution rate: Pink-tinged urine is expected in the early hours after a TURP due to residual bleeding from the surgical site. The nurse should continue the current irrigation rate to prevent clot formation and maintain catheter patency.

B. Warm the irrigation solution: Warming the solution is not required for bladder irrigation and does not address the normal postoperative finding of pink-tinged urine. It also does not play a role in preventing clot formation.

C. Perform the Credé's maneuver: This technique, involving manual bladder compression, is not appropriate for a client with a continuous bladder irrigation and indwelling catheter in place. It could cause injury or disrupt the surgical site.

D. Replace the indwelling urinary catheter: There is no indication of catheter blockage or malfunction in this scenario. Replacing the catheter unnecessarily increases infection risk and could damage the urethra or surgical area.

A. Temperature 38.2° C (100.8° F) B. Heart rate 104/min C. Respiratory rate 18/min D. BP 108/70 mm Hg E. SaO2 97% on room air F. Client reports feeling unwell. G. Client states breasts feel firm, heavy, and warm with moderate nipple discomfort while breastfeeding. H. Fundus boggy but firmed with massage. I. Moderate amount of dark brown, foul-smelling lochia noted. J. Surgical incision well approximated with slight edema present no redness or drainage noted. K. No bowel movement since birth, hypoactive bowel sounds. L. WBC count 33,000/mm3 (5,000 to 10,000/mm3)

Correct Answer is ["A","B","F","H","I","L"]

Explanation

Rationale for correct choices:

Temperature 38.2° C (100.8° F): An elevated temperature in the postpartum period may indicate infection, particularly given the prolonged rupture of membranes and cesarean birth. Early recognition is essential to prevent progression to sepsis.
Heart rate 104/min: Tachycardia can be an early sign of infection or postpartum hemorrhage. In combination with fever and elevated WBC, this warrants prompt evaluation.
Client reports feeling unwell: The client’s report of illness is the first indicator of an ongoing disease process which warrants further evaluation, coupled by other findings, this indicates that there is something wrong.
WBC count 33,000/mm³: This is markedly elevated beyond the normal postpartum range and indicates a possible systemic infection. This finding requires immediate intervention and notification of the provider.
Fundus boggy but firmed with massage: A boggy uterus suggests uterine atony, which increases the risk of postpartum hemorrhage. Continuous monitoring is needed to prevent excessive blood loss.
Moderate amount of dark brown, foul-smelling lochia: Foul-smelling lochia is a sign of endometritis or uterine infection. Early identification and treatment reduce the risk of sepsis and further complications.

Rationale for incorrect choices:

Vital Signs Respiratory rate 18/min, BP 108/70 mm Hg, SaO₂ 97% on room air: This is within normal limits and does not indicate respiratory compromise at this time. Blood pressure is within normal postpartum range; no immediate intervention is needed. Oxygen saturation is adequate and does not require urgent follow-up.
Breast firmness with moderate nipple discomfort: These findings are consistent with normal lactation and engorgement, and do not indicate an immediate complication.
Surgical incision well-approximated with slight edema: Mild edema without redness or drainage is expected postoperatively and does not require immediate intervention.
No bowel movement since birth, hypoactive bowel sounds: While monitoring is necessary for constipation, this is a common postpartum finding, especially after surgery and opioid use, and does not require urgent intervention.

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A nurse is assessing a client who is experiencing a hypertensive crisis. Which of the following manifestations should the nurse expect?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate 4 hr ago. The nurse notes pink-tinged urine in the drainage bag. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

Correct Answer is ["A","B","F","H","I","L"]

Explanation

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