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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. The ST segment is elevated above the isoelectric line: This is correct. ST-segment elevation is a key ECG finding in acute myocardial infarction. It indicates that a portion of the heart muscle is not receiving enough blood (ischemia), which can lead to tissue damage or death (infarction).

B. The PR intervals are 0.15 second: While the PR interval is an important part of the ECG, a PR interval of 0.15 second is within the normal range and does not indicate an acute myocardial infarction.

C. The QT interval is equal to the R to R interval: The QT interval represents the time from the start of the Q wave to the end of the T wave, encompassing ventricular depolarization and repolarization. While prolonged or shortened QT intervals can be associated with certain cardiac conditions, they are not specific indicators of an acute myocardial infarction.

D. The QRS intervals are 0.08 second: The QRS interval represents ventricular depolarization1. A QRS interval of 0.08 second is within the normal range and does not indicate an acute myocardial infarction.

Correct Answer is ["2"]

Explanation

Let's calculate how many tablets the nurse should administer:

Dosage prescribed: The doctor prescribed digoxin 0.25 mg.

Tablet strength: Each available tablet contains 0.125 mg of digoxin.

To find out how many tablets are needed, we can divide the prescribed dosage by the amount of digoxin per tablet:

Number of tablets = Prescribed dosage / Amount of digoxin per tablet

Number of tablets = 0.25 mg / 0.125 mg/tablet

Since we might get a decimal result due to the division, we need to round to the nearest whole number of tablets the nurse can administer for safety reasons.

In this case, dividing 0.25 mg by 0.125 mg/tablet gives us 2.

Therefore, rounding up to the nearest whole number of tablets, the nurse should administer 2 tablets.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who was admitted to the cardiac telemetry unit after he experienced chest pain, dyspnea and diaphoresis. Which of the following electrocardiogram (ECG) findings is a manifestation of acute myocardial infarction?

Correct Answer is A

Explanation

A nurse is preparing to administer digoxin 0.25 mg PO to a client. The amount available is digoxin 0.125 mg tablets. How many tablets should the nurse administer to the client? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["2"]

Explanation

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