The nurse is caring for a client in a hypertensive emergency. Which action will be included in the plan of care during hypertensive emergency who is receiving nifedipine?

Organize nursing activities so that the patient has 8 hours of undisturbed sleep at night.

Use an automated noninvasive blood pressure machine to obtain frequent measurements.

Keep the hypertensive emergency NPO to prevent aspiration caused by nausea and possible vomiting.

Assist the patient up in the chair for meals to avoid complications associated with immobility.

Answer and Explanation

The Correct Answer is B

The action that will be included in the plan of care for a client in a hypertensive emergency receiving nifedipine is to use an automated noninvasive blood pressure machine to obtain frequent measurements.

In a hypertensive emergency, the client's blood pressure is severely elevated, requiring immediate treatment and close monitoring. Nifedipine is a calcium channel blocker commonly used to lower blood pressure in such situations. Continuous blood pressure monitoring is crucial to assess the effectiveness of the medication and ensure that the blood pressure is brought under control safely.

Organize nursing activities so that the patient has 8 hours of undisturbed sleep at night: While providing a conducive environment for sleep is important for overall patient well-being, in a hypertensive emergency, the priority is to manage and monitor the blood pressure. Sleep hygiene may not be the immediate concern in this situation.

Keep the hypertensive emergency NPO to prevent aspiration caused by nausea and possible vomiting: NPO (nothing by mouth) orders are typically implemented when there is a risk of aspiration or pending a procedure requiring anesthesia. In a hypertensive emergency, the focus is on managing blood pressure and ensuring appropriate hydration and nutrition as needed. NPO status may not be necessary unless speciﬁcally indicated for the individual patient.

Assist the patient up in the chair for meals to avoid complications associated with immobility: While mobilization and preventing complications associated with immobility are important aspects of care, in a hypertensive emergency, the primary focus is on managing blood pressure and stabilizing the client's condition. Mobilization may be appropriate once the blood pressure is under control and the client's condition permits.

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Correct Answer is B

Explanation

The most appropriate nursing intervention to improve adhesion of the ECG leads on a male client with abundant chest hair is to clip the chest hair with the patient's permission before applying the leads. Chest hair can interfere with the adhesion of the ECG leads, resulting in poor signal quality and potentially affecting the accuracy of the ECG recording. By clipping the chest hair, the nurse can improve the contact between the skin and the ECG leads, allowing for better adhesion and signal transmission.

It is important to obtain the patient's permission before clipping the chest hair to respect their autonomy and ensure their comfort during the procedure. The nurse should explain the reason for clipping the hair and address any concerns or questions the patient may have.

Let's review the other options and explain why they are not the most appropriate interventions:

Using alcohol swabs to clean the skin before applying the leads: While cleaning the skin with alcohol swabs is a routine practice to remove oils and dirt that can affect adhesion, it may not be sufficient in the presence of abundant chest hair. Clipping the hair would be more effective in this situation.

Applying the leads to the arms and legs only: This option would not provide an accurate 12-lead ECG recording, as the chest leads are essential for evaluating the electrical activity of the heart from different angles. It is important to have the leads properly placed on the chest for an accurate assessment.

Rescheduling the ECG: Unless there are other valid reasons for rescheduling, such as a medical condition that contraindicates the procedure, rescheduling solely due to abundant chest hair would be unnecessary. Clipping the hair is a practical and effective solution to improve adhesion.

A. Document the information as a normal finding B. Prepare the client for an arterial bypass C. Educate the client about the use of compression stocking D. Anticipate a prescription for clopidogrel and simvastatin

Correct Answer is C

Explanation

Based on the information provided, an Ankle-Brachial Index (ABI) of 0.89 indicates a mild reduction in blood flow to the lower extremities, suggesting peripheral arterial disease (PAD). In this case, the nurse should educate the client about the use of compression stockings.

Compression stockings are a conservative management approach for peripheral arterial disease. They help improve blood flow and alleviate symptoms by applying pressure to the legs, promoting venous return, and reducing swelling. Educating the client about the use of compression stockings can help improve circulation and manage symptoms such as pain, cramping, and fatigue.

Let's review the other options and explain why they are not the most appropriate interventions in this scenario:

Document the information as a normal finding: An ABI of 0.89 indicates an abnormal finding suggestive of peripheral arterial disease. It should not be documented as a normal finding, as it requires further assessment and intervention.

Prepare the client for an arterial bypass: An arterial bypass is a surgical intervention that is typically reserved for more severe cases of peripheral arterial disease. With an ABI of 0.89, which indicates mild reduction in blood flow, arterial bypass is not the first-line intervention. Conservative measures and medical management are usually recommended initially.

Anticipate a prescription for clopidogrel and simvastatin: Medications like clopidogrel (antiplatelet) and simvastatin (statin) may be prescribed for peripheral arterial disease. However, the next appropriate step after obtaining an ABI of 0.89 would be to educate the client about the use of compression stockings as a conservative management option before considering medication therapy.

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The nurse is caring for a client in a hypertensive emergency. Which action will be included in the plan of care during hypertensive emergency who is receiving nifedipine?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing a 12-lead ECG on a male client with abundant chest hair. What is the most appropriate nursing intervention to improve adhesion of the ECG leads?

Correct Answer is B

Explanation

The nurse is assessing a client with a presumptive diagnosis of peripheral arterial disease. The nurse obtains an Ankle-Brachial index of 0.89. Which intervention should the nurse take next?

Correct Answer is C

Explanation

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