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 B

Explanation

A. Diltiazem: Diltiazem is a calcium channel blocker used to treat high blood pressure and heart rhythm disorders. However, it can further lower the heart rate, which is not desirable in this case as the client’s heart rate is already low.

B. Atropine: This is correct. Atropine is often used to treat bradycardia (low heart rate). It works by blocking the action of the vagus nerve on the heart, which increases the heart rate.

C. Digoxin: Digoxin is used to treat heart failure and atrial fibrillation1. However, one of its side effects is that it can lower the heart rate, so it would not be appropriate to give to a client who already has a low heart rate.

D. Carvedilol: Carvedilol is a beta-blocker used to treat high blood pressure and heart failure1. Like other beta-blockers, it can lower the heart rate, so it would not be appropriate to give to a client who already has a low heart rate.

A. pH 7.48 B. pH 7.50 C. pH 7.31 D. pH 7.39

Correct Answer is C

Explanation

A. pH 7.48:

A pH of 7.48 indicates alkalosis, not acidosis. Respiratory acidosis is characterized by a pH below the normal range (7.35-7.45).

B. pH 7.50:

Similar to choice A, a pH of 7.50 indicates alkalosis, not acidosis.

C. pH 7.31:

This pH value falls below the normal range (7.35-7.45), indicating acidemia. In respiratory acidosis, there is an increase in the partial pressure of carbon dioxide (PaCO2) in the blood, leading to an accumulation of carbonic acid and a decrease in pH.

D. pH 7.39:

A pH of 7.39 falls within the normal range (7.35-7.45), indicating a normal acid-base balance. It does not indicate acidosis.

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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?

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