You are caring for a client in the ED with B/P 254/139 mm Hg. Which of the following actions would you take first?

Elevate the head of the client’s bed

Contact the Rapid Response Team

Tell the client to report vision changes

Insert a peripheral IV

Initiate seizure precautions

Answer and Explanation

The Correct Answer is B

Choice A reason:

Elevating the head of the client’s bed can help reduce blood pressure slightly by promoting venous return and decreasing intracranial pressure. However, this action alone is not sufficient to address the severe hypertension (254/139 mm Hg) the client is experiencing. Immediate medical intervention is required to prevent complications such as stroke, heart attack, or organ damage.

Choice B reason:

Contacting the Rapid Response Team is the highest priority action. The Rapid Response Team is trained to handle critical situations and can provide immediate interventions to stabilize the client’s condition. Severe hypertension at this level requires urgent medical attention to prevent life-threatening complications. The team can administer medications to lower blood pressure quickly and monitor the client closely.

Choice C reason:

Telling the client to report vision changes is important because vision changes can indicate hypertensive retinopathy or increased intracranial pressure. However, this action is not the immediate priority. The client’s blood pressure needs to be controlled urgently to prevent further complications.

Choice D reason:

Inserting a peripheral IV is necessary for administering medications and fluids. While this is an important step, it should follow the immediate action of contacting the Rapid Response Team. The team can then use the IV access to administer antihypertensive medications promptly.

Choice E reason:

Initiating seizure precautions is important because severe hypertension can lead to seizures. However, this action is not the first priority. The primary focus should be on stabilizing the client’s blood pressure through immediate medical intervention.

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Correct Answer is D

Explanation

Choice A Reason:

Low oxygen saturation is not a common side effect of donepezil. Donepezil is a cholinesterase inhibitor used to treat symptoms of Alzheimer’s disease by increasing the levels of acetylcholine in the brain. While it can have various side effects, respiratory issues like low oxygen saturation are not typically associated with this medication. Therefore, monitoring for low oxygen saturation is not a primary concern for patients starting donepezil.

Choice B Reason:

High blood pressure is also not a common side effect of donepezil. The medication primarily affects the central nervous system and does not typically cause significant changes in blood pressure. While it is always important to monitor a patient’s overall health, high blood pressure is not a side effect specifically linked to donepezil use. Therefore, it is not a primary focus for monitoring in this context.

Choice C Reason:

Elevated body temperature is not commonly associated with donepezil. The side effects of donepezil are more likely to involve gastrointestinal issues such as nausea, vomiting, and diarrhea, as well as muscle cramps and fatigue. Elevated body temperature is not a typical reaction to this medication, so it is not a primary concern for monitoring.

Choice D Reason:

Low pulse rate, or bradycardia, is a known side effect of donepezil. Donepezil can increase the levels of acetylcholine, which can affect the heart’s electrical conduction system and lead to a slower heart rate. This can be particularly concerning in elderly patients or those with pre-existing heart conditions. Therefore, it is crucial for the nurse to teach the family to monitor the client’s pulse rate regularly and report any significant decreases to the healthcare provider.

A. Administer 0.45% NS at 50 mL/hr B. Obtain daily weight C. Maintain seizure precautions D. Administer 3% saline as ordered E. Encourage fluid intake

Correct Answer is ["B","C","D"]

Explanation

Choice A Reason:

Administering 0.45% NS (normal saline) at 50 mL/hr is not appropriate for a client with SIADH. This hypotonic solution can exacerbate the condition by increasing the water retention and further diluting the serum sodium levels, worsening hyponatremia. Instead, fluid restriction and hypertonic saline (such as 3% saline) are typically used to manage SIADH.

Choice B Reason:

Obtaining daily weight is crucial in managing SIADH. Daily weights help monitor fluid retention and detect any sudden changes in body weight, which can indicate worsening fluid overload or effective treatment. Accurate weight measurements are essential for assessing the client’s fluid balance and guiding treatment decisions.

Choice C Reason:

Maintaining seizure precautions is necessary for clients with SIADH because severe hyponatremia can lead to neurological symptoms, including seizures. Implementing seizure precautions helps ensure the client’s safety and allows for prompt intervention if a seizure occurs.

Choice D Reason:

Administering 3% saline as ordered is appropriate for treating severe hyponatremia in SIADH. Hypertonic saline helps increase serum sodium levels and reduce the risk of neurological complications. It must be administered carefully and under close monitoring to avoid rapid correction of sodium levels, which can lead to osmotic demyelination syndrome.

Choice E Reason:

Encouraging fluid intake is not appropriate for clients with SIADH. Fluid restriction is a key component of managing SIADH to prevent further dilution of serum sodium levels. Encouraging fluid intake would counteract this goal and worsen the client’s condition.

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You are caring for a client in the ED with B/P 254/139 mm Hg. Which of the following actions would you take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is planning health teaching for a client starting on donepezil for Alzheimer’s disease (AD). For which side effect will the nurse teach the family to monitor?

Correct Answer is D

Explanation

The nurse is planning care for a client diagnosed with SIADH. Which of the following would be included in the plan of care? Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

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