A nurse is caring for a client who has severe hypertension and is to receive nitroprusside via continuous IV infusion.
Which of the following actions should the nurse plan to take?
Keep calcium gluconate at the client's bedside.
Attach an inline filter to the IV tubing.
Protect the IV bag from exposure to light.
Monitor blood pressure every 2 hr.
The Correct Answer is C
Answer is: c. Protect the IV bag from exposure to light.
Explanation: Nitroprusside degrades when exposed to light, so the nurse should protect the IV bag from light exposure to maintain the medication's potency and effectiveness in treating the client's severe hypertension.
Choice a. is wrong because calcium gluconate is used as an antidote for magnesium sulfate toxicity. Although it may be kept on hand in some facilities, it is not directly related to the administration of nitroprusside.
Choice b. is wrong because attaching an inline filter is not necessary when administering nitroprusside. It is more relevant for medications that require filtration, such as certain chemotherapeutic agents.
Choice d. is wrong because monitoring blood pressure every 2 hours is not frequent enough for a client receiving nitroprusside. The nurse should monitor the client's blood pressure more frequently, such as every 5 to 15 minutes, depending on facility policies and the client's condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Managing conflict within the group is an important skill, but it is more appropriate for the working phase of group therapy. During the orientation phase, the focus is on establishing trust, setting group norms, and creating a safe environment. Conflict resolution skills become more relevant as the group progresses.
Choice B rationale:
Encouraging the use of problem-solving skills is essential in group therapy, but it is a skill that is developed during the working phase. During the orientation phase, the nurse focuses on building rapport, creating a comfortable atmosphere, and explaining the purpose and goals of the group.
Choice C rationale:
Maintaining the group's focus on identified issues is a crucial aspect of the orientation phase. The nurse should guide the discussion to ensure that participants understand the purpose of the group and stay on topic. This helps in establishing clear goals and expectations for the group sessions.
Choice D rationale:
Establishing a rapport with group members is a primary goal of the orientation phase. Building trust and a therapeutic relationship with the adolescents creates a supportive environment where they feel comfortable sharing their experiences and emotions. A strong rapport enhances the effectiveness of the support group.
Correct Answer is A
Explanation
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