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 D

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: Elevating the bed may reduce intracranial pressure but is less urgent than starting an IV for antihypertensive drugs. IV access is the priority, making this incorrect, as it delays the critical intervention to manage the client’s severe hypertension in the emergency department.

Choice D reason: Starting a peripheral IV is the first action to enable rapid administration of antihypertensive medications in hypertensive crisis. This aligns with emergency care protocols for blood pressure 254/139 mm Hg, making it the correct initial step to stabilize the client’s condition.

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 D

Explanation

Choice A reason: Referring to the ethics committee is premature without discussing the patient’s wishes with the family. Asking about the patient’s preferences respects autonomy, making this incorrect, as it bypasses the family’s role in decision-making for the unresponsive patient.

Choice B reason: Asking what the family wants is vague and may pressure them without context. Inquiring about the patient’s wishes guides ethical decisions, making this incorrect, as it’s less focused than the nurse’s approach to honor the patient’s likely preferences.

Choice C reason: Stating the doctor’s recommendation may bias the family and doesn’t explore the patient’s wishes. Asking what the patient would want is more patient-centered, making this incorrect, as it’s less collaborative in discussing ongoing care options.

Choice D reason: Asking what the patient would want respects autonomy and guides family decision-making in the absence of an advance directive. This aligns with ethical principles, making it the correct approach for the nurse to discuss ongoing care with the family.

A. A patient with a fractured femur who is receiving a dose of opioid pain medication and reports a pain level of 8/10. B. A patient who has just returned from a colonoscopy and is stable but complaining of minor bloating. C. A patient with newly diagnosed Type 1 diabetes who is receiving insulin for the first time and reports confusion. D. A patient with a history of heart failure who has a blood pressure of 90/60 mmHg and is lethargic.

Correct Answer is D

Explanation

Choice A reason: Pain of 8/10 is significant, but the patient is receiving opioids, and pain is less immediately life-threatening than hypotension and lethargy. This is incorrect, as it’s lower priority than the nurse’s need to address a patient with unstable vital signs.

Choice B reason: Minor bloating post-colonoscopy is expected and stable, not requiring immediate intervention. Hypotension in heart failure is critical, making this incorrect, as it’s less urgent than the nurse’s priority to manage a patient with potential decompensation.

Choice C reason: Confusion in new Type 1 diabetes may indicate hypoglycemia, but hypotension and lethargy in heart failure suggest acute decompensation, a higher priority. This is incorrect, as it’s less critical than the nurse’s focus on the heart failure patient’s instability.

Choice D reason: Hypotension (90/60 mmHg) and lethargy in a heart failure patient indicate possible cardiogenic shock, requiring immediate intervention. This aligns with prioritization in acute care, making it the correct patient for the charge nurse to prioritize for urgent assessment and action.

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

Correct Answer is D

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?

Correct Answer is D

Explanation

You are working on a busy unit and need to delegate tasks to the LPN and M

The nurse provides instructions to a client about measures to treat irritable bowel syndrome (IBS). Which statement by the client indicates a need for further teaching?

The nurse in the emergency department (ED) is assessing a client with anaphylactic shock. Which of the following findings would support a diagnosis of anaphylactic shock? (Select all that apply)

The nurse caring for a client with chronic obstructive pulmonary disease (COPD) anticipates which arterial blood gas (ABG) findings?

A client had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse?

During transport to the operating room for mitral valve replacement, a patient with a signed consent form says that she does not want to go through with the surgery and asks to be returned to her room. What is the best response from the nurse?

A nurse is providing teaching to a client who has venous insufficiency of the lower extremities. Which of the following statements by the client indicates an understanding of the teaching?