A nurse is caring for a client who is experiencing a hypertensive crisis. Which of the following actions should the nurse take?
Initiate an IV dopamine infusion.
Begin an IV bolus of lactated Ringer's.
Perform neurological assessments.
Place the client supine.
The Correct Answer is C
A hypertensive crisis is an emergent situation in which a marked elevation in diastolic blood pressure can cause end-organ damage.
The nurse should perform neurological assessments to monitor for any changes in the patient’s level of consciousness and other neurological symptoms.
Choice A is incorrect because dopamine is not typically used to treat hypertensive crises.
Choice B is incorrect because lactated Ringer’s solution is not typically used to treat hypertensive crises.
Choice D is incorrect because placing the client supine may not be appropriate and could potentially worsen their condition.
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Related Questions
Correct Answer is D
Explanation
The client’s ABG results show a pH of 7.24, which is below the normal range of 7.35-7.45 and indicates acidosis.
The PaCO2 is within the normal range of 35-45 mm Hg, indicating that the acidosis is not caused by a respiratory issue.
The HCO3 level is 18 mEq/L, which is below the normal range of 22-28 mEq/L and indicates a primary metabolic cause for acidosis.
Respiratory acidosis is not indicated by the ABG results as the PaCO2 is within the normal range.
B) Metabolic alkalosis is not indicated by the ABG results as the pH and HCO3 levels are below their respective normal ranges.
C) Respiratory alkalosis is not indicated by the ABG results as the pH is below the normal range and the PaCO2 is within the normal range.
Correct Answer is D
Explanation
The first action the nurse should take is to collect information about the irritant that caused the injury.
This information is important because it can help determine the appropriate treatment and irrigation solution to use.
Choice A is incorrect because airborne precautions are used to prevent the spread of infectious diseases that are transmitted through the air, and are not necessary in this situation.
Choice B is incorrect because administering proparacaine eye drops into the affected eye is not the first action the nurse should take.
Proparacaine is a topical anesthetic that can be used to numb the eye before performing ocular irrigation, but it is not the first action the nurse should take.
Choice C is incorrect because installing 0.9% sodium chloride solution into the affected eye is not the first action the nurse should take; the nurse should first collect information about the irritant that caused the injury before performing ocular irrigation.
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