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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason: A bedside table 2 feet away hinders reach, increasing fall risk. It should be closer for safe access to essentials in bed.

Choice B reason: Dim lighting obscures hazards, raising fall risk. Bright, even illumination is needed to enhance visibility for a client prone to falling.

Choice C reason: Area rugs on slick floors create tripping hazards, worsening fall risk. Secure or remove them to stabilize footing for safety.

Choice D reason: Moving the bed downstairs eliminates stair falls, a major risk. It’s a key environmental adaptation for safe mobility in at-risk clients.

A. Offer the client several choices at mealtimes. B. Alternate daily caregivers. C. Avoid discussing the client’s fears. D. Remind the client of the day and time often.

Correct Answer is D

Explanation

Choice A reason: Offering multiple choices overwhelms a delirious client, whose impaired cognition struggles with decisions. Scientifically, delirium reduces attention and processing, so simplifying options aids comfort, making this counterproductive to managing their acute confusional state effectively.

Choice B reason: Alternating caregivers disrupts continuity, worsening disorientation in delirium. Consistent faces aid recognition, reducing anxiety. Scientifically, familiarity stabilizes perception in acute confusion, making this detrimental to the client’s need for a predictable environment during recovery.

Choice C reason: Avoiding fears ignores emotional distress, potentially increasing agitation in delirium. Addressing concerns gently can calm. Scientifically, unaddressed anxiety exacerbates confusion, so this neglects a holistic approach needed for managing the client’s psychological state effectively.

Choice D reason: Reminding of day and time reorients the client, countering delirium’s disorientation. Frequent cues anchor perception, aiding recovery. Scientifically, this aligns with evidence-based care, as repeated orientation reduces confusion’s impact, supporting cognitive stabilization in acute delirium management.

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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?

Nursing Test Bank

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