The client diagnosed with primary hypertension says, "I don't know why the doctor is worried about my blood pressure. I am feeling just fine." Which statement by the nurse would be the most appropriate?

You feel good because your medication is working properly.

Your blood pressure reflects how strong your heart muscle contracts.

Even if you are feeling good, damage can occur to your heart and kidneys.

Have you told your doctor that you are feeling good?

Answer and Explanation

The Correct Answer is C

Choice A reason: You feel good because your medication is working properly is not the most appropriate statement by the nurse. This statement may imply that the client does not need to worry about their blood pressure or follow up with their doctor. The nurse should educate the client about the importance of regular monitoring and adherence to the prescribed treatment.

Choice B reason: Your blood pressure reflects how strong your heart muscle contracts is not the most appropriate statement by the nurse. This statement may confuse the client or give them a false sense of security. The nurse should explain that blood pressure is determined by the force and amount of blood pumped by the heart and the resistance of the blood vessels. The nurse should also inform the client about the normal and abnormal ranges of blood pressure and the risk factors for hypertension.

Choice C reason: Even if you are feeling good, damage can occur to your heart and kidneys is the most appropriate statement by the nurse. This statement conveys the seriousness of hypertension and its potential complications. The nurse should educate the client about the effects of high blood pressure on the vital organs and the need for preventive measures and lifestyle modifications.

Choice D reason: Have you told your doctor that you are feeling good is not the most appropriate statement by the nurse. This statement may suggest that the nurse is not interested in the client's condition or does not have the knowledge or authority to address their concerns. The nurse should communicate effectively with the client and the health care team and provide appropriate guidance and support.

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Free Nursing Study Resources

Correct Answer is ["A","B","E"]

Explanation

Choice A reason: Pregnancy can increase the frequency and severity of sickle cell crises⁵⁶. Regular prenatal care is especially important for women with sickle cell disease⁵⁶. Therefore, it's crucial for a young female adult with sickle cell anemia to be aware that pregnancy increases the risk of crisis.

Choice B reason: Low oxygen levels can trigger a sickle cell crisis³. Therefore, avoiding travel to cities where the oxygen level is lower can help prevent crises.

Choice C reason: While regular, moderate exercise can be beneficial, strenuous exercise can lead to dehydration and fatigue, which can trigger a sickle cell crisis⁹[^10^]¹¹. Therefore, the statement that strenuous exercise prevents the development of sickle cell crisis is not accurate.

Choice D reason: Commercial airlines have controlled cabin pressure and oxygen levels, so flying is generally safe for individuals with sickle cell disease¹²³. However, it's always best to discuss travel plans with a healthcare provider³. Therefore, avoiding flying on commercial airlines is not necessarily a requirement.

Choice E reason: Dehydration can increase the risk of a sickle cell crisis, so it's important to drink plenty of fluids, especially in hot weather³.

A. Assess the apical pulse and if above 60 beats/minute administer the dose. B. Administer 0.25 mcg and potassium 20 mEq IV. C. Withhold the medication and notify the healthcare provider of the digoxin level. D. Administer the digoxin with a potassium supplement.

Correct Answer is C

Explanation

Choice A reason: This is incorrect. Assessing the apical pulse is not enough to determine if the client is safe to receive digoxin. The client's digoxin level is already above the therapeutic range of 0.5 to 2 ng/mL¹² and giving another dose could increase the risk of toxicity and arrhythmias.

Choice B reason: This is incorrect. Administering 0.25 mcg of digoxin and potassium 20 mEq IV is not appropriate for this client. The client does not need more digoxin or potassium, as both could worsen the client's condition. Potassium levels should be monitored closely in clients taking digoxin, as low or high levels can affect the drug's action and toxicity³.

Choice C reason: This is correct. Withholding the medication and notifying the healthcare provider of the digoxin level is the most appropriate action for this client. The client's digoxin level is dangerously high and could cause serious adverse effects such as nausea, vomiting, vision changes, bradycardia, and cardiac arrest³. The healthcare provider may order to stop digoxin temporarily, adjust the dose, or prescribe an antidote such as digoxin immune fab⁴.

Choice D reason: This is incorrect. Administering the digoxin with a potassium supplement is not advisable for this client. The client's digoxin level is already too high and adding potassium could increase the risk of hyperkalemia, which can impair the heart's electrical activity and lead to cardiac arrest³. Potassium supplements should only be given to clients with digoxin-induced hypokalemia, and only under the supervision of the healthcare provider³..

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The client diagnosed with primary hypertension says, "I don't know why the doctor is worried about my blood pressure. I am feeling just fine." Which statement by the nurse would be the most appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse should instruct a young female adult with sickle cell anemia to do which of the following? (Select all that apply)

Correct Answer is ["A","B","E"]

Explanation

The nurse prepares to administer digoxin 0.125 mg PO to a client who has chronic heart failure. The laboratory report reveals a digoxin level of 2.5 mg/mL. Which nursing action is most appropriate at this time?

Correct Answer is C

Explanation

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