A client who receives an antihypertensive medication daily is NPO except medications for surgery. The most recent blood pressure recording is 174/88. What action should the nurse take first?

Notify the surgeon of the blood pressure.

Document the blood pressure on the pre-op checklist.

Have the client relax and take deep breaths.

Administer the antihypertensive medication.

Answer and Explanation

The Correct Answer is D

Choice A Reason:

Notifying the surgeon of the blood pressure is important, but it is not the first action the nurse should take. The primary concern is to manage the patient’s high blood pressure to prevent any complications during surgery. Once the blood pressure is under control, the nurse can then notify the surgeon if necessary.

Choice B Reason:

Documenting the blood pressure on the pre-op checklist is a necessary step, but it is not the immediate priority. The nurse’s first action should be to address the elevated blood pressure to ensure the patient’s safety. Documentation can be done after the immediate concern is managed.

Choice C Reason:

Having the client relax and take deep breaths can help lower blood pressure temporarily, but it is not a sufficient intervention for a blood pressure reading as high as 174/88. The nurse should take a more direct approach to manage the hypertension, such as administering the prescribed antihypertensive medication.

Choice D Reason:

Administering the antihypertensive medication is the most appropriate first action. The patient is NPO (nothing by mouth) except for medications, indicating that the medication should still be given. This action directly addresses the elevated blood pressure and helps to stabilize the patient before surgery.

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Correct Answer is A

Explanation

Choice A reason:

A pH of 7.37, PaO2 of 90 mmHg, PaCO2 of 44 mmHg, and HCO3 of 22 mEq/L indicate a near-normal acid-base balance and adequate oxygenation. The pH is within the normal range (7.35-7.45), suggesting that the client’s acid-base status has improved. The PaO2 is also within the normal range (80-100 mmHg), indicating good oxygenation.

Choice B reason:

A pH of 7.36, PaO2 of 60 mmHg, PaCO2 of 45 mmHg, and HCO3 of 22 mEq/L indicate a slightly acidic pH and hypoxemia (low PaO2). While the pH is close to normal, the low PaO2 suggests that the client is still experiencing significant respiratory distress.

Choice C reason:

A pH of 7.48, PaO2 of 80 mmHg, PaCO2 of 32 mmHg, and HCO3 of 18 mEq/L indicate alkalosis (high pH) and a low PaCO2, which may suggest hyperventilation. This is not an improved acid-base status as it indicates an imbalance.

Choice D reason:

A pH of 7.27, PaO2 of 70 mmHg, PaCO2 of 38 mmHg, and HCO3 of 14 mEq/L indicate acidosis (low pH) and hypoxemia. This result suggests that the client is still in significant respiratory distress and has not achieved an improved acid-base status.

A. Administer their inhaler medications and increase the oxygen. B. Notify the physician and administer lorazepam. C. Dim the lights and encourage the client to take a nap. D. Sit with the client and provide comfort measures.

Correct Answer is D

Explanation

Choice A reason:

Administering inhaler medications and increasing oxygen may be necessary if the client is experiencing respiratory distress. However, since the client is not currently reporting increased dyspnea, this intervention is not immediately required. The focus should be on addressing the client’s anxiety.

Choice B reason:

Notifying the physician and administering lorazepam may be appropriate if the client’s anxiety is severe and not manageable through non-pharmacological means. However, it is generally best to try comfort measures and non-pharmacological interventions first.

Choice C reason:

Dimming the lights and encouraging the client to take a nap can help reduce anxiety, but it may not be the most effective initial intervention. Providing direct comfort and reassurance is often more beneficial in addressing immediate anxiety.

Choice D reason:

Sitting with the client and providing comfort measures is the most appropriate intervention. This approach helps to alleviate anxiety through direct support and reassurance. Techniques such as deep breathing exercises, talking calmly, and providing a comforting presence can significantly reduce anxiety.

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A client who receives an antihypertensive medication daily is NPO except medications for surgery. The most recent blood pressure recording is 174/88. What action should the nurse take first?

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