A nurse is caring for four clients. Which one would the nurse see first?

Client who needs a beta blocker, and has a blood pressure of 98/58 mm Hg.

Hypertensive client with a blood pressure of 156/90 mm Hg.

Client who needs pain medication prior to a dressing change of a surgical wound.

Client who had a first dose of captopril and needs to use the bathroom.

Answer and Explanation

The Correct Answer is A

A. A client with low blood pressure (98/58 mm Hg) who requires a beta blocker should be seen first because beta blockers can lower blood pressure further, possibly leading to hypotension or dizziness.

B. A hypertensive client with a blood pressure of 156/90 mm Hg is stable and does not require immediate intervention.

C. While pain medication is important, it is not as urgent as addressing a client with low blood pressure and a medication that can worsen the condition.

D. The client who just had captopril can wait to use the bathroom, as the priority is addressing their blood pressure and captopril's effect.

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Correct Answer is D

Explanation

A. Increasing IV fluids would exacerbate the client's fluid overload and worsen heart failure symptoms.

B. Trendelenburg positioning is typically used for shock management, but this client’s fluid overload needs to be addressed first.

C. Monitoring is important but does not address the immediate need to manage fluid overload.

D. The client's elevated CVP, PAWP, and BNP levels indicate fluid overload and heart failure with reduced ejection fraction. The priority is to reduce fluid overload by administering IV diuretics, which will help reduce the pressure in the heart and lungs, improving oxygenation and decreasing the risk of pulmonary edema.

A. Lantus insulin 24 U subcutaneously every evening B. Oral digoxin (Lanoxin) 0.25 mg daily C. Metoprolol (Lopressor) 12.5 mg orally daily D. Ibuprofen (Motrin) 400 mg every 6 hours

Correct Answer is B

Explanation

A. Lantus insulin does not directly affect potassium levels in the same way that digoxin does.

B. A potassium level of 3.0 mEq/L is low, and digoxin toxicity can occur when potassium levels are low, leading to an increased risk of arrhythmias. This requires immediate attention to avoid serious complications.

C. Metoprolol is a beta-blocker that does not directly cause hypokalemia and is less of an immediate concern.

D. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that could affect kidney function but does not directly impact potassium levels as significantly as digoxin.

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A nurse is caring for four clients. Which one would the nurse see first?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A client who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.0 mEq/L. The nurse should alert the health care provider immediately that the client is on which medication?

Correct Answer is B

Explanation

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