A nurse is administering an IV antihypertensive to a client who has a BP of 185/130 mm Hg. Which of the following actions should the nurse take first?
Check for orthostatic hypertension.
Instruct the client to restrict sodium intake.
Assist the client to make lifestyle changes.
Monitor the client's BP every 5 minutes.
The Correct Answer is D
A. Check for orthostatic hypertension: While checking for orthostatic hypertension is important; it is not the first action a nurse should take when administering an IV antihypertensive. The priority is to monitor the client’s response to the medication.
B. Instruct the client to restrict sodium intake: While dietary modifications such as sodium restriction can help manage hypertension, it is not the immediate concern when administering an IV antihypertensive. The priority is to monitor the client’s response to the medication.
C. Assist the client to make lifestyle changes: Lifestyle changes are a crucial part of managing hypertension, but they are not the immediate concern when administering an IV antihypertensive. The priority is to monitor the client’s response to the medication.
D. Monitor the client’s BP every 5 minutes: This is the correct answer. When administering an IV antihypertensive, it is crucial to closely monitor the client’s blood pressure to assess the effectiveness of the medication and to ensure the client’s safety. The client’s high blood pressure of 185/130 mm Hg is a serious condition that requires immediate and careful management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
(A) Blood pressure 160/94 mm Hg:
Metoprolol is a beta-blocker commonly used to treat hypertension. A blood pressure reading of 160/94 mm Hg indicates hypertension, which is an indication for administering metoprolol, not withholding it.
(B) Oxygen saturation 95%:
An oxygen saturation of 95% is within the normal range and does not provide a reason to withhold metoprolol. Oxygen saturation levels are not directly impacted by this medication in a way that would warrant withholding it.
(C) Heart rate 50/min:
A heart rate of 50/min is bradycardia (a slow heart rate). Metoprolol can further lower the heart rate, so it should be withheld if the client is already experiencing bradycardia. The nurse should notify the healthcare provider for further instructions.
(D) Respiratory rate 18/min:
A respiratory rate of 18/min is within the normal range (12-20 breaths per minute) and does not provide a reason to withhold metoprolol. Respiratory rate is not typically a contraindication for this medication unless there are specific respiratory conditions or other related symptoms present.
Correct Answer is A
Explanation
A) Atropine:
Atropine is a medication used to increase heart rate. It acts by blocking the parasympathetic nervous system, leading to increased heart rate. It is commonly used to treat bradycardia, which is characterized by a heart rate less than 60 beats per minute. In this scenario, with the client's apical heart rate at 49/min, indicating bradycardia, the nurse should prepare to administer atropine to increase the heart rate.
B) Verapamil:
Verapamil is a calcium channel blocker that can decrease heart rate. It is used to treat various cardiac conditions, but it is not appropriate for a client with bradycardia, as it would further lower the heart rate.
C) Digoxin:
Digoxin is a medication used to treat heart failure and certain arrhythmias, but it does not directly increase heart rate. In fact, it can exacerbate bradycardia in some cases.
D) Carvedilol:
Carvedilol is a beta-blocker that can decrease heart rate. It is used to treat hypertension, heart failure, and other cardiovascular conditions, but it is not appropriate for a client with bradycardia, as it would further lower the heart rate.
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