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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
“The client’s capillary refill in the left toe is 6 seconds.” Capillary refill time is the time it takes for blood to return to the capillaries after pressure has been applied to the skin.
A normal capillary refill time is less than 2 seconds.
A capillary refill time of 6 seconds indicates poor blood flow to the left toe and requires immediate intervention by the nurse.
Choice B is not the correct answer because while a pain level of 7 on a scale from 0 to 10 at the operative site is concerning, it does not require immediate intervention by the nurse.
Choice C is not the correct answer because an oral temperature of 38.3° C (100.9° F) is only slightly elevated and does not require immediate intervention by the nurse.
Choice D is not the correct answer because while 100 mL of blood in a closed-suction drain may be concerning, it does not necessarily require immediate intervention by the nurse.
Correct Answer is A
Explanation
The nurse should ensure that the client is discharged with antithrombotic pharmacologic therapy.
Antithrombotic medications help prevent blood clots from forming and can reduce the risk of another ischemic stroke.
Choice B is wrong because diuretics are used to treat fluid retention and high blood pressure and are not typically used for stroke prevention.
Choice C is wrong because anticonvulsants are used to prevent seizures and are not typically used for stroke prevention.
Choice D is wrong because opioid analgesics are used to treat pain and are not typically used for stroke prevention.
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