Which of the following describes a situation in which the blood pressure is severely elevated and there is evidence of actual target organ damage?

Secondary hypertension

Hypertensive urgency

Hypertensive emergency

Primary hypertension

Answer and Explanation

The Correct Answer is C

A. Secondary hypertension is high blood pressure due to an identifiable cause, such as renal disease, but it does not describe an acute situation with target organ damage.

B. Hypertensive urgency is a situation where the blood pressure is severely elevated but without evidence of target organ damage.

C. Hypertensive emergency is characterized by severely elevated blood pressure with evidence of acute target organ damage, such as encephalopathy, myocardial infarction, or renal failure, requiring immediate medical intervention.

D. Primary hypertension, also known as essential hypertension, is high blood pressure without a known secondary cause and does not describe an acute emergency.

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Correct Answer is B

Explanation

A. Obtaining a stat chest x-ray is important if catheter misplacement is suspected, but in this situation, ensuring the accuracy of the pressure reading through proper leveling and zeroing is the priority.
B. Zero referencing and leveling the catheter at the phlebostatic axis is essential to ensure accurate readings of the pulmonary artery pressure, which is critical for patient assessment and management.
C. Increasing supplemental oxygen is unnecessary given the patient’s stable oxygen saturation and normal respiratory status.
D. While notifying the provider is important, ensuring the accuracy of the pressure reading by leveling and zeroing the catheter should be done first.

A. Provide passive range of motion for all extremities. B. Position the patient supine with head flat at all times. C. Measure the patient's urinary output every hour. D. Avoid the use of anticoagulant medications.

Correct Answer is C

Explanation

A. Passive range of motion may be performed, but it is not the priority in this situation.

B. The head of the bed should be elevated 30 degrees or less, not necessarily flat, to prevent complications.

C. Hourly urinary output measurement is essential because the intra-aortic balloon pump (IABP) can impair renal perfusion, and monitoring urine output helps assess renal function.

D. Anticoagulants are often necessary to prevent clot formation associated with the IABP, so avoiding them is not advised unless contraindicated.

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Which of the following describes a situation in which the blood pressure is severely elevated and there is evidence of actual target organ damage?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

The nurse is caring for a patient who has an intraaortic balloon pump in place. Which action should be included in the plan of care?

Correct Answer is C

Explanation

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