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. Increase in postoperative pain: Preoperative teaching typically includes information about pain management strategies, which should help to reduce, not increase, postoperative pain.

B. Reduced postoperative anxiety: This is correct. One of the key benefits of preoperative education is reduced anxiety. By understanding what to expect before, during, and after surgery, patients are often less anxious about the procedure.

C. Reduced postoperative respiratory function: Preoperative teaching usually includes instructions on deep breathing and coughing exercises to help prevent respiratory complications after surgery. Therefore, it should improve, not reduce, postoperative respiratory function.

D. Increased length of postoperative care in the health care facility: Preoperative education has been shown to reduce the length of hospital stay. By better understanding their surgery and postoperative care, patients are often able to recover more quickly and leave the hospital sooner

A. A 14-month-old toddler who is reportedly learning to walk and has several bruises on bony prominences of the lower legs and elbows. B. A9-month-old infant who sustained near drowning when he reportedly climbed into the tub and turned on the water C. A3-year-old toddler with scalding burns over the face and chest reportedly sustained when the child pulled on tablecloth, spilling a cup of tea on himself. D. A 6-year-old child who has a spiral fracture of the tibia and fibula, which reportedly occurred while riding a bicycle

Correct Answer is D

Explanation

A. A 14-month-old toddler with bruises on bony prominences:

Bruises on bony prominences are common in toddlers who are learning to walk and are prone to falls. While bruising can raise concerns, it is not necessarily indicative of physical abuse, especially in this age group.

B. A 9-month-old infant who sustained near drowning:

Near drowning in an infant who climbed into the tub and turned on the water suggests an accidental event rather than physical abuse. This scenario is consistent with lack of supervision or an unfortunate accident.

C. A 3-year-old toddler with scalding burns:

Scalding burns from spilling hot tea on oneself can occur accidentally, especially in young children who may not understand the dangers associated with hot liquids. While the circumstances may raise suspicion, it does not necessarily indicate physical abuse without further evidence.

D. A 6-year-old child with a spiral fracture:

A spiral fracture of the tibia and fibula is concerning for physical abuse, especially in a child who reportedly sustained the injury while riding a bicycle. Spiral fractures are often associated with twisting or pulling forces and are considered suspicious for non-accidental trauma, particularly when there is no plausible explanation for the injury.

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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

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