A nurse is caring for a client who has chronic kidney failure. An assistive personnel reports that the client has a blood pressure of 190/110mm Hg. Which of the following actions should the nurse take first?
Report the blood pressure reading to the charge nurse.
Administer an antihypertensive medication.
Remeasure the client's blood pressure.
Instruct the client to remain in bed.
The Correct Answer is C
A. Report the blood pressure reading to the charge nurse: While notifying the charge nurse is important, the nurse should first validate the high reading by rechecking the blood pressure. Acting on a single, unverified reading could lead to unnecessary interventions or missed opportunities for accurate assessment.
B. Administer an antihypertensive medication: Administering antihypertensive medication based solely on a report without rechecking the blood pressure could be unsafe. Verification ensures that treatment is based on accurate clinical data and prevents unnecessary medication administration.
C. Remeasure the client's blood pressure: The first action should always be to recheck an unusually high or abnormal vital sign reading to confirm its accuracy. Errors can occur during measurement, and accurate confirmation is critical before proceeding with further interventions in a client with chronic kidney failure.
D. Instruct the client to remain in bed: While keeping the client in bed can help prevent complications if severe hypertension is confirmed, it is not the priority action. Verifying the blood pressure reading must occur first to determine the appropriate course of action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Take vital signs on clients as they are admitted: Taking vital signs is within the scope of practice for assistive personnel (AP) and is an essential task during a mass casualty event. It provides critical baseline information that the licensed staff can use to prioritize care and identify urgent needs.
B. Respond to family members about a client's condition: Communicating about a client's medical condition requires clinical judgment and is the responsibility of licensed nursing staff or healthcare providers. APs are not trained or authorized to give out clinical information to family members.
C. Clean and dress client abdominal wounds: Wound care, especially for open or surgical wounds like those on the abdomen, involves assessment and sterile technique, which must be performed by licensed personnel, not assistive personnel.
D. Determine which clients should be seen first: Determining client priority, also known as triage, requires nursing knowledge, critical thinking, and clinical assessment skills. It is a responsibility that falls to licensed nurses, not assistive personnel.
Correct Answer is ["0.25"]
Explanation
Desired dose = 0.25 mg
Available concentration = 1 mg/mL
Calculate the volume to administer:
Volume to administer (mL) = Desired dose (mg) / Available concentration (mg/mL)
= 0.25 mg / 1 mg/mL
= 0.25 mL
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