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: Metoprolol, a beta-blocker, lowers BP, causing orthostatic hypotension. Caution when standing prevents falls, showing grasp of this key side effect.
Choice B reason: Leafy greens affect warfarin, not metoprolol. No dietary restriction applies, so this reflects confusion about beta-blocker side effects.
Choice C reason: Weight gain, not loss, may occur with metoprolol from fluid retention. Expecting loss misinterprets its metabolic impact, indicating misunderstanding.
Choice D reason: Taste loss isn’t a metoprolol effect; it’s linked to other drugs. This shows incorrect attribution of side effects to the medication.
Correct Answer is C
Explanation
Choice A reason: Brewed green tea has 25-40 mg caffeine per 8 oz, from tea leaves’ natural stimulants. It exceeds cocoa, making it a higher-caffeine choice.
Choice B reason: Cola soft drinks contain 30-50 mg caffeine per 8 oz, added artificially. This surpasses cocoa’s level, placing it higher in caffeine content.
Choice C reason: Hot cocoa has 5-15 mg caffeine per 8 oz, naturally low from cocoa beans. It’s the least caffeinated option among these beverages.
Choice D reason: Instant coffee delivers 60-100 mg caffeine per 8 oz, concentrated from coffee grounds. It’s far higher than cocoa, unsuitable for reduction.
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