A nurse is collecting data from a client who has chronic kidney failure. An assistive personnel reports that the client has a blood pressure of 190/110 mm Hg. Which of the following actions should the nurse take first?
Remeasure the client's blood pressure.
Administer an antihypertensive medication.
Report the blood pressure reading to the charge nurse.
Instruct the client to remain in bed.
The Correct Answer is A
Choice A reason: Remeasuring confirms the 190/110 mm Hg reading, ensuring accuracy in kidney failure, where hypertension is common. It’s the first step before acting.
Choice B reason: Administering medication without verification risks error; BP may be inaccurate. In kidney failure, precise BP guides therapy, so this waits.
Choice C reason: Reporting to the charge nurse follows confirmation; unverified readings waste time. Accuracy in chronic kidney failure is critical before escalating.
Choice D reason: Bed rest may help, but confirming BP first prioritizes data. Kidney failure needs validated hypertension readings to direct immediate care safely.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Remeasuring confirms the 190/110 mm Hg reading, ensuring accuracy in kidney failure, where hypertension is common. It’s the first step before acting.
Choice B reason: Administering medication without verification risks error; BP may be inaccurate. In kidney failure, precise BP guides therapy, so this waits.
Choice C reason: Reporting to the charge nurse follows confirmation; unverified readings waste time. Accuracy in chronic kidney failure is critical before escalating.
Choice D reason: Bed rest may help, but confirming BP first prioritizes data. Kidney failure needs validated hypertension readings to direct immediate care safely.
Correct Answer is B
Explanation
Choice A reason: Limiting coffee reduces acid stimulation, but it’s not the primary GERD strategy. Elevating the bed prevents reflux via gravity, making this a secondary suggestion compared to positional therapy.
Choice B reason: Elevating the bed head keeps acid in the stomach during sleep, reducing esophageal irritation. This evidence-based intervention is a key GERD management technique for symptom relief.
Choice C reason: Large meals increase gastric pressure, exacerbating reflux in GERD. Smaller, frequent meals are advised instead, so this contradicts best practice, worsening the condition rather than helping.
Choice D reason: Lying down after eating promotes acid reflux into the esophagus, worsening GERD. Upright positioning post-meal is preferred, making this an incorrect and harmful recommendation.
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