A nurse is caring for a client who has acute kidney injury. The client's ABGS are:

PH:7.26

PaCO2: 30 mm Hg

HCO3: 14 mEq/L

Which of the following acid-imbalances should the nurse identify the client is experiencing?

A. Check for orthostatic hypertension: While checking for orthostatic hypertension is important; it is not the first action a nurse should take when administering an IV antihypertensive. The priority is to monitor the client’s response to the medication.

B. Instruct the client to restrict sodium intake: While dietary modifications such as sodium restriction can help manage hypertension, it is not the immediate concern when administering an IV antihypertensive. The priority is to monitor the client’s response to the medication.

C. Assist the client to make lifestyle changes: Lifestyle changes are a crucial part of managing hypertension, but they are not the immediate concern when administering an IV antihypertensive. The priority is to monitor the client’s response to the medication.

D. Monitor the client’s BP every 5 minutes: This is the correct answer. When administering an IV antihypertensive, it is crucial to closely monitor the client’s blood pressure to assess the effectiveness of the medication and to ensure the client’s safety. The client’s high blood pressure of 185/130 mm Hg is a serious condition that requires immediate and careful management.

A. A critical pathway for clients who have had a stroke:
Critical pathways are structured multidisciplinary care plans that outline essential steps in the care of patients with specific conditions. While critical pathways are valuable tools for standardized care, they are not specifically focused on health promotion activities for clients with hypertension.

B. Standards of care for monitoring clients who have a history of blood pressure elevation:
Standards of care typically outline the minimum level of care that should be provided to clients based on evidence-based practice. While monitoring clients with a history of blood pressure elevation is important, it does not encompass the comprehensive health promotion activities related to hypertension.

C. Acute care facility protocols for clients experiencing an abrupt change in mental status:
Acute care facility protocols are designed to guide the management of acute changes in a patient's condition. While relevant to patient care, these protocols do not specifically address health promotion activities for clients with hypertension.

D. Clinical practice guidelines for the management of high blood pressure:
Clinical practice guidelines provide evidence-based recommendations for the management of specific health conditions. They typically include information on health promotion activities, risk factor modification, lifestyle interventions, and pharmacological management for clients with hypertension. Therefore, clinical practice guidelines are the most appropriate resource for information on health promotion activities for clients with hypertension.