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 D
Explanation
Choice A reason: Fluconazole treats fungal infections, not RSV, a viral respiratory illness. Antivirals like ribavirin might apply, but antifungals don’t. Scientifically, this mismatches RSV’s etiology, as it’s a paramyxovirus, rendering fluconazole ineffective and irrelevant for managing this preschooler’s condition.
Choice B reason: Monitoring urine for protein assesses kidney function, unrelated to RSV, which affects lungs. Proteinuria isn’t a typical RSV sign. Scientifically, this lacks relevance, as RSV causes respiratory distress, not renal complications, making it an unnecessary action here.
Choice C reason: An X-ray of the neck targets croup or epiglottitis, not RSV, which affects lower airways. RSV needs chest imaging if severe. Scientifically, neck imaging misaligns with RSV’s pathophysiology, wasting resources when lung assessment is more pertinent.
Choice D reason: Droplet precautions prevent RSV spread via respiratory droplets, critical in preschoolers who aerosolize virus easily. Scientifically, this aligns with infection control, as RSV’s high contagiousness requires masks and isolation to protect others, a primary nursing action per guidelines.
Correct Answer is C
Explanation
Choice A reason: Taping to the cheek risks skin injury and tube displacement in kids. Abdominal securing is safer for gastrostomy stability and comfort.
Choice B reason: Extension tubes are for feeding, not routine site care. Attaching one now is premature, unrelated to maintaining the site itself.
Choice C reason: Securing to the abdomen prevents pulling or dislodgement of the gastrostomy tube. It’s a standard care step, ensuring stability and safety.
Choice D reason: Lubricant isn’t needed for site care; it may irritate skin. Clean, dry maintenance is preferred, making this an incorrect action.
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