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 D

Explanation

Pursed-lip breathing is a technique used to help manage shortness of breath and improve ventilation. It involves breathing in through the nose and exhaling slowly through pursed lips, as if blowing out a candle. This method helps to keep the airways open longer, allowing more air to escape and reducing the work of breathing.

Choice A reason:

Exhale quickly and forcefully through the mouth is not the correct intervention for pursed-lip breathing. Exhaling quickly and forcefully can cause the airways to collapse, making it harder to breathe out all the air. This can lead to air trapping and increased shortness of breath, which is counterproductive for clients with respiratory issues.

Choice B reason:

Inhale sharply with a “huff” sound is also not correct for pursed-lip breathing. Huff coughing is a technique used to clear mucus from the airways, not to manage breathing patterns. Inhaling sharply can cause irritation and may not provide the controlled breathing needed for effective gas exchange.

Choice C reason:

Inhale deeply through pursed lips is incorrect. The correct technique for pursed-lip breathing involves inhaling through the nose, not through pursed lips. Inhaling through the nose helps to filter and humidify the air, making it easier on the lungs and airways.

Choice D reason:

Exhale slowly through pursed lips is the correct intervention. This technique helps to prolong exhalation, which reduces the respiratory rate and improves ventilation. By keeping the airways open longer, it helps to release trapped air and improve oxygenation. This method is particularly beneficial for clients with chronic obstructive pulmonary disease (COPD) and asthma, as it helps to reduce the work of breathing and improve overall respiratory function.

A. Fever and bradypnea B. Dyspnea and wheezing C. Crackles and productive cough D. Normal chest shape and orthopnea

Correct Answer is B

Explanation

Choice A reason:

Fever and bradypnea are not typical manifestations of asthma. Fever is more commonly associated with infections, and bradypnea (abnormally slow breathing) is not a characteristic symptom of asthma.

Choice B reason:

Dyspnea (shortness of breath) and wheezing are hallmark symptoms of asthma. Asthma is characterized by inflammation and narrowing of the airways, which leads to difficulty breathing and a whistling sound (wheezing) when exhaling. These symptoms are often triggered by allergens, exercise, or respiratory infections.

Choice C reason:

Crackles and a productive cough are more indicative of conditions like pneumonia or chronic bronchitis rather than asthma. Asthma typically involves a dry cough rather than a productive one.

Choice D reason:

A normal chest shape and orthopnea (difficulty breathing when lying flat) are not specific to asthma. While some individuals with severe asthma may develop a barrel chest over time due to chronic overinflation of the lungs, this is not a typical early manifestation.

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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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