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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: Administering furosemide without a provider’s order is outside nursing scope and risks harm. Decreasing IV fluids addresses elevated CVP, making this incorrect, as it bypasses protocol compared to the nurse’s priority of adjusting fluids and consulting the provider.

Choice B reason: A CVP of 16 cm H2O suggests fluid overload; decreasing IV fluids and notifying the provider prevents worsening heart failure. This aligns with hemodynamic monitoring protocols, making it the correct action for the nurse to take to address the client’s elevated CVP.

Choice C reason: Documenting the CVP is necessary but doesn’t address the urgent fluid overload indicated by 16 cm H2O. Decreasing fluids is proactive, making this incorrect, as it delays intervention compared to the nurse’s priority of managing the client’s high CVP.

Choice D reason: Checking urine specific gravity assesses hydration but is less urgent than addressing elevated CVP with fluid adjustment. Notifying the provider takes precedence, making this incorrect, as it’s secondary to the nurse’s action to manage fluid overload immediately.

A. “I have had unprotected sex with multiple partners.” B. “I ate shellfish about 2 weeks ago at a local restaurant.” C. “I was an intravenous drug abuser in the past and shared needles.” D. “I had a blood transfusion 30 years ago after major abdominal surgery.”

Correct Answer is B

Explanation

Choice A reason: Unprotected sex is a risk for hepatitis B or C, not A, which is fecal-oral. Shellfish consumption is a common source, making this incorrect, as it doesn’t support the nurse’s diagnosis of hepatitis A based on the client’s history.

Choice B reason: Eating contaminated shellfish is a common cause of hepatitis A, transmitted via the fecal-oral route, with symptoms appearing 2-6 weeks later. This aligns with the diagnosis, making it the correct statement supporting the client’s hepatitis A diagnosis.

Choice C reason: Sharing needles spreads hepatitis B or C, not A, which is foodborne. Shellfish is a hepatitis A source, making this incorrect, as it’s unrelated to the nurse’s evaluation of the client’s flu-like symptoms and jaundice.

Choice D reason: Blood transfusions before 1992 risked hepatitis C, not A, which is fecal-oral. Eating shellfish supports hepatitis A, making this incorrect, as it doesn’t align with the nurse’s diagnosis based on the client’s jaundice and flu-like symptoms.

View Question and Answer

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

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse cares for a client with 0.9% sodium chloride infusing at 125 mL/h. 2 hours after the infusion was started, the client’s central venous pressure (CVP) reading is 16 cm H2O. It is MOST important for the nurse to take which action?

Correct Answer is B

Explanation

The primary health care provider has determined that a client has contracted hepatitis A based on flu-like symptoms and jaundice. Which statement made by the client supports this medical diagnosis?

Correct Answer is B

Explanation

You are the charge nurse in a busy med-surg unit. There are several patients under your care, and you are managing a group of nurses. Which patient should be prioritized for immediate intervention?

The nurse is providing dietary education to a client with gastroesophageal reflux disease (GERD). The nurse indicates that the client understands the teaching if the client states a plan to avoid which foods to prevent symptom exacerbation? (Select all that apply)

The nurse is planning to teach a client with gastroesophageal reflux disease (GERD) about substances to avoid. Which items would the nurse include on this list? (Select all that apply)

A client is admitted to the ED with a burn injury. The client’s vital signs are the following: blood pressure: 72/48, heart rate: 152 beats/min, respiratory rate: 26/min. He is pale in color and the nurse is unable to feel his pedal pulses. Which action will the nurse take first?

The nurse is educating a patient with iron deficiency anemia about food sources high in iron and how to enhance the absorption of iron when eating these foods. What can the nurse inform the client would enhance the absorption?

The laboratory notifies the night nurse that the patient has a critical magnesium level of 1.1 mEq/L. The patient has a do-not-resuscitate order. The nurse does not inform the practitioner because of the patient’s code status. In doing so, the nurse is negligent for which action?

A client with chronic kidney disease being hemodialyzed suddenly becomes short of breath and complains of chest pain. The client is tachycardic, pale, and anxious, and the nurse suspects air embolism. What are the priority nursing actions? (Select all that apply)

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?