At 0800, the practical nurse (PN) reports to the registered nurse (RN) that a client’s blood pressure is 140/90 mm Hg. When the RN arrives to administer the 0900 antihypertensive medication, the client is oriented but lethargic, pale, and diaphoretic. Which action should the RN implement first?

Obtain another measurement of the client’s blood pressure.

Determine what medications the client recently received.

Administer the antihypertensive medication as prescribed.

Consult with the PN about the client’s condition at 0800.

Answer and Explanation

The Correct Answer is A

Choice A reason: Obtaining another blood pressure measurement is critical, as lethargy, pallor, and diaphoresis suggest hypotension or shock, despite the earlier 140/90 reading. This guides safe administration of antihypertensives, preventing harm, per cardiovascular assessment and medication safety protocols in nursing practice.

Choice B reason: Determining recent medications is important but secondary to assessing current blood pressure, as symptoms suggest acute instability. Blood pressure confirms hypotension risk before reviewing drugs, ensuring timely intervention, per cardiovascular assessment and patient safety standards in nursing care.

Choice C reason: Administering antihypertensives without reassessing blood pressure is unsafe, as lethargy, pallor, and diaphoresis indicate possible hypotension. Confirming blood pressure prevents exacerbating instability, per medication safety and cardiovascular monitoring protocols in nursing practice for clients with hypertension.

Choice D reason: Consulting the PN about the 0800 condition delays immediate assessment of current symptoms. Blood pressure measurement addresses acute lethargy, pallor, and diaphoresis, guiding intervention. Consultation is secondary, per prioritization and cardiovascular assessment standards in nursing care.

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Correct Answer is C

Explanation

Choice A reason: Placing the chair by the bed is preparatory but not immediate after sitting up. Prolonged bedrest risks orthostatic hypotension from reduced plasma volume and baroreceptor sensitivity. Assessing the client’s response ensures stability before transfer, preventing falls, making this less urgent than evaluating for dizziness or hypotension.

Choice B reason: Supporting the client when rising is premature before assessing their response to sitting. Bedrest causes deconditioning, increasing orthostatic hypotension risk, leading to dizziness or syncope. Determining how the client feels confirms cardiovascular stability, preventing falls during transfer due to blood pressure drops.

Choice C reason: Determining how the client feels assesses for orthostatic hypotension, common post-bedrest due to reduced venous return and baroreceptor dysfunction. Dizziness or lightheadedness signals syncope risk during transfer. This ensures cardiovascular stability, prioritizing safety before physical support, addressing physiological changes from prolonged immobility.

Choice D reason: Offering non-skid socks prevents falls during ambulation but is secondary to assessing sitting response. Bedrest heightens hypotension risk, and ensuring the client is not dizzy takes precedence to avoid syncope. Socks are a later safety measure, making this less immediate than evaluating physiological stability.

A. “I should avoid activities that increase eye pressure, like heavy lifting.” B. “Glaucoma can lead to vision loss if not managed properly.” C. “Eye drops will cure my glaucoma and restore my vision.” D. “Regular eye exams are important to monitor my condition.”

Correct Answer is C

Explanation

Choice A reason: Avoiding heavy lifting is correct, as it increases intraocular pressure (IOP) in glaucoma, damaging the optic nerve. This statement shows understanding, as limiting activities that elevate IOP protects retinal ganglion cells, reducing progression risk, aligning with proper glaucoma management strategies.

Choice B reason: Glaucoma can cause vision loss if untreated, as elevated IOP damages optic nerve fibers, leading to irreversible blindness. This statement reflects accurate understanding of the disease’s progressive nature, emphasizing the need for management to preserve vision, requiring no further teaching.

Choice C reason: Eye drops (e.g., timolol) reduce IOP but do not cure glaucoma or restore vision, as optic nerve damage is irreversible. This statement indicates misunderstanding, as glaucoma is chronic, requiring lifelong management to slow progression, necessitating further teaching to correct this misconception.

Choice D reason: Regular eye exams monitor IOP and optic nerve health in glaucoma, preventing progression. This statement shows understanding, as consistent follow-up detects changes in retinal nerve fiber layer thickness, ensuring timely adjustments in therapy, aligning with effective disease management.

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At 0800, the practical nurse (PN) reports to the registered nurse (RN) that a client’s blood pressure is 140/90 mm Hg. When the RN arrives to administer the 0900 antihypertensive medication, the client is oriented but lethargic, pale, and diaphoretic. Which action should the RN implement first?

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Naxlex Comprehensive Predictor Exams

After a week of bedrest, a client is being assisted to a chair for the first time. The nurse raises the head of the bed and moves the client to a sitting position. Which action should the nurse implement next?

Correct Answer is C

Explanation

The nurse is teaching a client with newly diagnosed glaucoma about the condition. Which statement by the client indicates a need for further teaching?

Correct Answer is C

Explanation

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Which instruction should the nurse provide a client who was recently diagnosed with Raynaud’s disease?

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Which nursing intervention is most effective in determining the severity of a client’s pain?

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