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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
A 42-year-old man with gastroesophageal reflux disease (GERD) is not at the highest risk for obstructive sleep apnea (OSA). While GERD can be associated with OSA, it is not a primary risk factor. The main risk factors for OSA include obesity, age, and anatomical features that can obstruct the airway. Therefore, this individual is not at the greatest risk compared to others.
Choice B Reason:
A 55-year-old woman who is 50 lb (23 kg) overweight is at significant risk for developing OSA. Obesity is one of the most critical risk factors for OSA because excess weight can lead to fat deposits around the upper airway, which can obstruct breathing during sleep. Additionally, being overweight increases the likelihood of other conditions that can exacerbate OSA, such as hypertension and metabolic syndrome.
Choice C Reason:
A 20-year-old woman who is 8 months pregnant may experience temporary sleep disturbances, including snoring and mild sleep apnea, due to hormonal changes and increased abdominal pressure. However, pregnancy-related sleep apnea is usually transient and resolves after childbirth. Therefore, while she may have an increased risk during pregnancy, it is not as significant as the risk posed by obesity.
Choice D Reason:
A 73-year-old man with type 2 diabetes mellitus has an increased risk of OSA, as diabetes is associated with obesity and metabolic syndrome, which are risk factors for OSA. However, the presence of diabetes alone does not pose as high a risk as obesity. Therefore, while this individual is at risk, it is not as high as the risk associated with being significantly overweight.
Correct Answer is D
Explanation
Choice A Reason:
Metabolic alkalosis is characterized by an elevated pH (greater than 7.45) and an increased bicarbonate (HCO3) level. In this case, the pH is 7.30, indicating acidosis, and the HCO3 level is 18 mEq/L, which is below the normal range (22-26 mEq/L). Therefore, metabolic alkalosis is not the correct diagnosis.
Choice B Reason:
Respiratory alkalosis is indicated by a high pH (greater than 7.45) and a low PaCO2 (less than 35 mm Hg). Although the PaCO2 is low at 28 mm Hg, the pH is 7.30, indicating acidosis rather than alkalosis. Therefore, respiratory alkalosis is not the correct diagnosis.
Choice C Reason:
Respiratory acidosis is characterized by a low pH (less than 7.35) and an elevated PaCO2 (greater than 45 mm Hg). In this case, the pH is low, indicating acidosis, but the PaCO2 is also low at 28 mm Hg, which does not fit the criteria for respiratory acidosis. Therefore, respiratory acidosis is not the correct diagnosis.
Choice D Reason:
Metabolic acidosis is indicated by a low pH (less than 7.35) and a low bicarbonate (HCO3) level (less than 22 mEq/L). In this case, the pH is 7.30, indicating acidosis, and the HCO3 level is 18 mEq/L, which is below the normal range. The low PaCO2 of 28 mm Hg suggests a compensatory respiratory response to the metabolic acidosis. Therefore, metabolic acidosis is the correct diagnosis.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today