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 B

Explanation

Choice A reason: Effective coughing after medication administration is not specifically required for the use of metered dose inhalers like albuterol and beclomethasone. While coughing can help clear mucus from the airways, it is not a necessary step in the administration of these medications. The primary focus should be on proper inhaler technique to ensure the medication reaches the lungs effectively.

Choice B reason: Rinsing the mouth after beclomethasone administration is crucial. Beclomethasone is an inhaled corticosteroid, and rinsing the mouth helps prevent oral thrush, a common side effect of inhaled steroids. Thrush is a fungal infection that can develop in the mouth and throat due to the residue of the medication. Proper rinsing and spitting out the water can significantly reduce the risk of this infection.

Choice C reason: Using beclomethasone as needed when breathing normally is incorrect. Beclomethasone is a maintenance medication that should be used regularly as prescribed, not on an as-needed basis. It helps control chronic inflammation in the airways and prevent asthma symptoms. Using it only when symptoms are not present would not provide the consistent anti-inflammatory effect needed to manage asthma effectively.

Choice D reason: Taking the beclomethasone first, followed by the albuterol, is incorrect. The correct sequence is to use the albuterol first. Albuterol is a bronchodilator that works quickly to open up the airways, making it easier for the beclomethasone to reach deeper into the lungs and be more effective

Correct Answer is ["10"]

Explanation

125 units of insulin in 250 mL of normal saline

Step 2: Calculate the concentration of insulin per mL.

Concentration = 125 units ÷ 250 mL
Concentration = 0.5 units/mL

Step 3: Determine the required rate of insulin administration.

Ordered dose = 5 units per hour

Step 4: Calculate the IV flow rate.

Flow rate (mL/hr) = Ordered dose ÷ Concentration
Flow rate (mL/hr) = 5 units ÷ 0.5 units/mL
Flow rate (mL/hr) = 10 mL/hr

The nurse should set the IV pump to 10 mL/hr.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is diagnosed with asthma. The therapeutic regimen using metered dose inhalers includes albuterol 2 puffs and beclomethasone 2 puffs. The nursing plan of care must include teaching regarding:

Correct Answer is B

Explanation

Correct Answer is ["10"]

Explanation

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