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","D","E"]

Explanation

Choice A Reason:

Cool, clammy skin is a common symptom in patients with atrial fibrillation, especially when the heart rate is very high. This symptom occurs due to decreased cardiac output, which leads to poor perfusion of the skin. When the heart is beating too fast, it doesn’t have enough time to fill properly, resulting in less blood being pumped out to the body. This can cause the skin to feel cool and clammy as the body tries to compensate for the reduced blood flow.

Choice B Reason:

Respiratory rate of 20 is within the normal range for adults, which is typically 12-20 breaths per minute. While it is important to monitor respiratory rate in patients with atrial fibrillation, a rate of 20 does not indicate any immediate distress or abnormality. Therefore, this choice is not particularly relevant to the assessment of a patient with a heart rate of 143 beats/min due to atrial fibrillation.

Choice C Reason:

Flushing of the skin is not a typical symptom associated with atrial fibrillation. Flushing can occur due to various reasons such as fever, anxiety, or certain medications, but it is not directly linked to the high heart rate or the irregular rhythm seen in atrial fibrillation. Therefore, this choice is not applicable in this context.

Choice D Reason:

Hypotension (low blood pressure) is a significant concern in patients with atrial fibrillation, especially when the heart rate is very high. The rapid heart rate can lead to decreased cardiac output, as the heart does not have enough time to fill properly between beats. This can result in lower blood pressure, which can cause symptoms such as dizziness, fainting, and fatigue. Monitoring blood pressure is crucial in managing patients with atrial fibrillation to prevent complications.

Choice E Reason:

Chest discomfort is a common symptom in patients with atrial fibrillation, particularly when the heart rate is very high. The irregular and rapid heart rate can cause the heart to work harder, leading to increased oxygen demand and potentially reduced oxygen supply to the heart muscle. This imbalance can result in chest pain or discomfort, which is a warning sign that the heart is under stress. It is important to assess and address chest discomfort promptly to prevent further cardiac complications.

A. A pulse of 86 beats/minute B. Hypoactive bowel sounds in all 4 quadrants C. Blood pressure of 110/70 mm Hg D. Increasing restlessness

Correct Answer is D

Explanation

Choice A Reason:

A pulse of 86 beats per minute is within the normal range for adults (60-100 beats per minute) and does not typically indicate a postoperative complication. While it is important to monitor vital signs, this pulse rate alone is not concerning unless accompanied by other abnormal findings.

Choice B Reason:

Hypoactive bowel sounds in all four quadrants can occur after surgery due to the effects of anesthesia and the surgical procedure itself. While it is important to monitor bowel sounds, hypoactivity is not immediately concerning unless it persists or is accompanied by other symptoms such as abdominal pain or distention. Therefore, this finding alone does not indicate an evolving complication.

Choice C Reason:

A blood pressure of 110/70 mm Hg is within the normal range for adults and does not typically indicate a postoperative complication. Blood pressure should be monitored regularly, but this reading alone is not concerning unless there are significant changes or other abnormal findings.

Choice D Reason:

Increasing restlessness is a concerning sign in the immediate postoperative period. It can indicate several potential complications, including pain, hypoxia, or the onset of delirium. Restlessness may also be an early sign of shock or other serious conditions that require prompt intervention. Therefore, this symptom warrants further assessment and immediate attention to determine the underlying cause and provide appropriate treatment.

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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 caring for a client with a heart rate of 143 beats/min with atrial fibrillation. Which assessment data will the nurse anticipate? Select all that apply:

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

Explanation

The nurse is monitoring the status of a postoperative client in the immediate postoperative period. The nurse would become most concerned with which sign that could indicate an evolving complication?

Correct Answer is D

Explanation

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