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 C
Explanation
Choice A reason: Erythromycin is specified, so the medication is clear. No ambiguity exists here for clarification. Scientifically, drug identity is explicit, and errors arise elsewhere, making this unnecessary to question unless a different antibiotic was intended, which isn’t suggested.
Choice B reason: Dosage (500 mg) is precise, with no range or units needing clarification. Scientifically, this is a standard erythromycin dose, aligning with therapeutic norms for infections, leaving little room for error unless misheard, which isn’t indicated.
Choice C reason: Route (e.g., oral, IV) isn’t stated, critical for erythromycin, as administration affects bioavailability and efficacy. Scientifically, unclear delivery risks under- or overdosing, necessitating provider clarification to ensure safe, effective treatment per pharmacological standards.
Choice D reason: Time (four times daily) is clear, aligning with erythromycin’s pharmacokinetics for steady levels. Scientifically, frequency is unambiguous, requiring no clarification unless intervals were vague, which they aren’t, making this less urgent than route.
Correct Answer is C
Explanation
Choice A reason: Antibiotics treat bacteria, not herpes, a viral infection. This is ineffective and risks resistance, making it an inappropriate intervention for simplex outbreaks.
Choice B reason: Povidone-iodine is harsh, delaying herpes healing by irritating lesions. Antivirals and gentle care are preferred, so this isn’t recommended for skin eruptions.
Choice C reason: OTC ointments can worsen herpes or delay healing without antiviral properties. Avoiding them ensures proper treatment, aligning with outbreak management guidelines.
Choice D reason: Disposable thermometers prevent cross-infection but don’t treat herpes directly. This is a general precaution, not a specific intervention for outbreak care.
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