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 A

Explanation

Choice A Reason:

Continuing to monitor is the most appropriate action in this scenario. The patient has a regular heart rhythm and a heart rate of 60 beats per minute, which is within the normal range for sinus bradycardia. The PR interval is 0.20 seconds, which is at the upper limit of normal. The patient’s vital signs are stable, with a blood pressure of 118/68 mm Hg, a respiratory rate of 16 breaths per minute, and a temperature of 98.8°F (37°C). There are no signs of hemodynamic instability or symptoms that would necessitate immediate intervention. Therefore, ongoing monitoring is sufficient to ensure the patient’s condition remains stable.

Choice B Reason:

Administering clonidine is not appropriate in this situation. Clonidine is an antihypertensive medication that can lower blood pressure and heart rate. Given that the patient’s blood pressure and heart rate are within normal ranges, administering clonidine could potentially cause hypotension and bradycardia, leading to adverse effects. Therefore, clonidine is not indicated for this patient.

Choice C Reason:

Administering atropine is not necessary for this patient. Atropine is used to treat symptomatic bradycardia, where the heart rate is abnormally slow and causing symptoms such as dizziness, hypotension, or syncope. In this case, the patient’s heart rate is 60 beats per minute, which is within the normal range for sinus bradycardia, and there are no symptoms indicating the need for atropine. Therefore, atropine is not required.

Choice D Reason:

Administering digoxin is also not appropriate. Digoxin is a cardiac glycoside used to treat heart failure and certain types of arrhythmias, such as atrial fibrillation. It can slow the heart rate and increase the force of cardiac contractions. In this scenario, the patient does not have any indications for digoxin therapy, such as heart failure or atrial fibrillation, and their heart rate is already within the normal range. Therefore, digoxin is not indicated.

A. QT interval B. Heart rate C. Respiratory rate D. Heart rhythm E. Urine output

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

Explanation

Choice A Reason:

Monitoring the QT interval is crucial when administering amiodarone because this drug can prolong the QT interval, increasing the risk of torsades de pointes, a potentially life-threatening type of ventricular tachycardia. Regular monitoring helps in early detection and management of this adverse effect, ensuring patient safety.

Title: Choice B Reason:

Heart rate monitoring is essential as amiodarone can cause bradycardia (slow heart rate). Continuous monitoring allows the nurse to detect any significant changes in heart rate and take appropriate actions, such as adjusting the medication dosage or providing interventions to manage bradycardia.

Title: Choice C Reason:

Respiratory rate monitoring is necessary because amiodarone can cause pulmonary toxicity, including interstitial pneumonitis and acute respiratory distress syndrome (ARDS). By keeping track of the respiratory rate, the nurse can identify early signs of respiratory complications and intervene promptly

Title: Choice D Reason:

Heart rhythm monitoring is vital since amiodarone is used to treat arrhythmias. Continuous electrocardiogram (ECG) monitoring helps in assessing the effectiveness of the drug in controlling arrhythmias and detecting any new or worsening arrhythmias that may require immediate attention.

Title: Choice E Reason:

Monitoring urine output is important because amiodarone can affect renal function, especially in patients with pre-existing kidney conditions. Keeping track of urine output helps in assessing renal function and ensuring that the drug is not causing nephrotoxicity

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The nurse administers amiodarone to a client with ventricular tachycardia. Which monitoring by the nurse is necessary with this drug? (Select all that apply)

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

Explanation

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