A nurse in an emergency department is caring for a client who has a blood pressure of 254/139 mm Hg. The nurse recognizes that the client is in a hypertensive crisis. Which of the following actions should the nurse take first?

Initiate seizure precautions.

Tell the client to report vision changes.

Elevate the head of the client’s bed.

Start a peripheral IV.

Answer and Explanation

The Correct Answer is C

Choice A reason: Seizure precautions are relevant but secondary to establishing IV access for antihypertensive administration in hypertensive crisis. Starting an IV enables immediate treatment, making this incorrect, as it delays the critical intervention needed to lower the client’s dangerously high blood pressure.

Choice B reason: Instructing to report vision changes monitors complications but doesn’t address the urgent need to lower blood pressure. IV access facilitates medication delivery, making this incorrect, as it postpones the primary action for managing the client’s hypertensive crisis effectively.

Choice C reason: Hypertensive crisis can cause severe headache, risk for stroke, pulmonary edema, and difficulty breathing. Elevating the HOB improves cerebral perfusion, reduces intracranial pressure, and eases breathing. This is an immediate, noninvasive, airway/circulation-supportive intervention.

Choice D reason: Needed for IV antihypertensive administration, but initial safety and circulation support (C) takes priority before establishing access.

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Correct Answer is C

Explanation

Choice A reason: Leg exercises prevent thrombosis post-gastrojejunostomy, a standard order. Irrigating the NG tube risks anastomosis disruption, making this incorrect, as it’s a safe prescription the nurse wouldn’t question in the client’s postoperative care plan.

Choice B reason: Early ambulation reduces complications like pneumonia after Billroth II surgery. Irrigating the NG tube is risky, making this incorrect, as it’s a standard order the nurse wouldn’t need to verify in the postoperative period.

Choice C reason: Irrigating the nasogastric tube post-gastrojejunostomy risks disrupting the surgical anastomosis, causing leakage. This requires verification, aligning with surgical safety, making it the correct prescription the nurse would question in the client’s postoperative care.

Choice D reason: Coughing and deep-breathing exercises prevent atelectasis post-surgery, a routine order. Irrigating the NG tube is concerning, making this incorrect, as it’s a safe prescription the nurse wouldn’t question in the client’s recovery plan.

A. Elevated creatinine level. B. Decreased hemoglobin level. C. Decreased red blood cell count. D. Increased number of white blood cells in the urine.

Correct Answer is A

Explanation

Choice A reason: Elevated creatinine is a hallmark of chronic kidney disease, reflecting reduced glomerular filtration rate. This aligns with renal function assessment, making it the correct finding the nurse would expect in a client with chronic kidney disease based on laboratory results.

Choice B reason: Decreased hemoglobin may occur in chronic kidney disease due to anemia, but it’s less specific than elevated creatinine, a direct renal marker. This is incorrect, as it’s secondary to the nurse’s primary expectation of creatinine elevation in kidney disease.

Choice C reason: Decreased red blood cell count accompanies anemia in kidney disease but is less direct than creatinine, which measures kidney function. This is incorrect, as it’s not the primary finding the nurse would expect compared to elevated creatinine levels.

Choice D reason: Increased white blood cells in urine suggest infection, not a universal finding in chronic kidney disease. Elevated creatinine is more consistent, making this incorrect, as it’s not the nurse’s primary expected lab result in kidney disease assessment.

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A nurse in an emergency department is caring for a client who has a blood pressure of 254/139 mm Hg. The nurse recognizes that the client is in a hypertensive crisis. Which of the following actions should the nurse take first?

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Naxlex Comprehensive Predictor Exams

A client with severe ulcer disease in the distal stomach undergoes a gastrojejunostomy (Billroth II procedure). Which postoperative prescription would the nurse question and verify?

Correct Answer is C

Explanation

The nurse is reviewing a client’s record and notes that the primary health care provider has documented that the client has chronic kidney disease. On review of the laboratory results, the nurse most likely would expect to note which finding?

Correct Answer is A

Explanation

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