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: Furosemide, a diuretic, increases urine output, reducing fluid overload in heart failure. This relieves pulmonary edema, showing the drug’s effectiveness clearly.
Choice B reason: Decreased hemoglobin isn’t tied to furosemide’s action; it reflects anemia, not fluid status. It doesn’t indicate diuretic efficacy in heart failure management.
Choice C reason: Weight gain signals fluid retention, opposite furosemide’s goal. Effective diuresis reduces weight, so this suggests treatment failure, not success.
Choice D reason: Decreased BUN may occur, but it’s not a primary furosemide marker. Urine output directly measures diuretic effect, making this less indicative.
Correct Answer is A
Explanation
Choice A reason: Injecting 15 units of air into regular insulin balances vial pressure, per protocol. This step precedes drawing regular insulin, ensuring accurate mixing sequence.
Choice B reason: Withdrawing NPH now skips regular insulin prep, risking contamination or error. Air injection into both vials comes first in standard insulin administration.
Choice C reason: Verification is key but follows insulin preparation. Air injection sequence precedes dosage checks, making this premature before completing vial prep steps.
Choice D reason: Capping the needle halts the process prematurely. Air must be injected into both vials first to maintain sterile technique and accurate dosing.
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