The client’s heart rate is 96 beats per minute, blood pressure is 220/129 mmHg, and respiratory rate is 18 breaths per minute.
The client is complaining of a headache. Ibuprofen was given as ordered.
Furosemide 50 mg IV was also given.
What should be the next step in the client’s care?
Attach the client to a continuous cardiac monitor
Place an indwelling urinary catheter
Give a fluid bolus
Draw a basic metabolic panel (BMP)
The Correct Answer is A
Choice A rationale
Given the client’s high blood pressure and complaint of a headache, it is important to continuously monitor the client’s cardiac status to detect any changes that may indicate worsening condition.
Choice B rationale
Placing an indwelling urinary catheter is not the immediate next step in this client’s care. While it may be necessary in some cases, it is not directly related to the client’s current symptoms.
Choice C rationale
Giving a fluid bolus is not the immediate next step in this client’s care. While it may be necessary in some cases, it is not directly related to the client’s current symptoms.
Choice D rationale
Drawing a basic metabolic panel (BMP) could be helpful in assessing the client’s overall health and kidney function, but it is not the immediate next step in this client’s care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While aged cheeses can interact with certain medications, they are not known to interact with tricyclic antidepressants or to have a significant impact on sleep patterns.
Choice B rationale
The timing of medication administration can significantly impact sleep patterns. If the patient is taking their medication upon rising, it could potentially be interfering with their sleep.
Choice C rationale
Dry mouth is a common side effect of tricyclic antidepressants. However, it is not typically associated with early morning awakening or difficulty returning to sleep.
Choice D rationale
Soaking in a warm bath at night can actually help promote sleep by raising the body’s core temperature and then allowing it to drop, which can trigger feelings of sleepiness.
Correct Answer is A
Explanation
Choice A rationale
If a child undergoing a blood transfusion complains of itchy skin and appears flushed, these
could be signs of a transfusion reaction. The PN should stop the transfusion immediately.
Choice B rationale
While inspecting the infusion site is a part of regular monitoring during a transfusion, it would
not typically be the first action in response to symptoms of a possible transfusion reaction.
Choice C rationale
Applying lotion to the skin would not address the underlying issue if the child is experiencing a
transfusion reaction.
Choice D rationale
Checking the vital signs is important, but the first action should be to stop the transfusion if a
reaction is suspected.
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