The nurse is administering nitroprusside by IV infusion for a client in hypertensive emergency. The nurse knows that the primary assessment will be:

Blood pressure due to the vasoconstriction action of this medication.

Intake/output due to the diuretic action of this medication.

Blood pressure due to the vasodilation action of this medication.

Peripheral pulses due to the vasoconstriction action of this medication.

Answer and Explanation

The Correct Answer is C

Nitroprusside is a potent vasodilator medication used to rapidly reduce blood pressure in hypertensive emergencies. Its primary action is to dilate blood vessels, leading to a decrease in systemic vascular resistance and subsequent reduction in blood pressure.

Monitoring the client's blood pressure is crucial during the administration of nitroprusside to ensure that the medication is achieving the desired effect and that blood pressure is being appropriately controlled. The nurse will assess blood pressure frequently to adjust the infusion rate and titrate the medication to achieve the desired therapeutic effect while avoiding hypotension or other adverse effects.

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Correct Answer is A

Explanation

A. Notify the surgeon that the informed consent process is not complete.The nurse should inform the surgeon because the surgeon is responsible for ensuring that the patient has adequate information and understands the procedure. It is not appropriate for the nurse to proceed with the consent process if the patient has questions or uncertainties.

B. Notify the operating room nurse to give a more complete explanation of the procedure.While the operating room nurse plays a role in the surgical process, it is the surgeon’s responsibility to provide a complete explanation of the procedure.

C. Provide a thorough explanation of the planned surgical procedure.While it’s important to provide information, the nurse is not authorized to explain the surgical procedure in detail. The surgeon should explain the surgery, as they have the training and knowledge to address all aspects of the procedure and answer any specific questions.

D. Give the prescribed preoperative antibiotics and withhold sedative medications.Administering preoperative medications, including antibiotics, without completed informed consent would be inappropriate. The patient must fully understand the procedure and consent to it before any medications are given.

A. Volvulus B. Paralytic ileus. C. Surgical adhesions/scar tissue D. Intestinal hernia.

Correct Answer is B

Explanation

A paralytic ileus is a type of bowel obstruction characterized by the impairment or absence of normal bowel motility. It occurs due to the temporary paralysis or dysfunction of the muscles that propel food and waste material through the intestines. After surgery, paralytic ileus can occur as a result of the handling of the intestines during the procedure, the effects of anesthesia, or the body's response to inflammation and trauma.

The absence of bowel sounds is a key indicator of paralytic ileus. Normally, bowel sounds are present and indicate the movement of contents through the intestines. However, in a paralytic ileus, the bowel sounds may be diminished or absent due to the lack of peristalsis (wave-like contractions that move food along the digestive tract).

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