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 C

Explanation

(A) Limit the client’s visitors to one at a time: While it’s important to maintain a peaceful environment for the client, limiting visitors may not be necessary unless the client’s condition is being negatively affected by too many visitors or if there are restrictions due to infection control.

(B) Avoid touching the client: Touch can be a powerful form of communication, especially when a client is unresponsive. Gentle touch can convey caring and presence, so avoiding touch is not typically recommended unless there’s a specific reason to do so (like if the client is in pain).

(C) Continue to talk to the client as if they are alive: This is the most appropriate answer. Even if a client is unresponsive, they may still be able to hear and understand. Continuing to talk to the client can provide comfort and reassurance.

(D) Whisper when talking in the client’s room: Whispering is not necessary and can even be confusing or distressing for the client. It’s better to speak in a normal, calm, and reassuring voice.

A. "I will try to anticipate and avoid stressful situations." B. "I will keep my house at a cool temperature." C. "I will complete the smoking cessation program I started." D. "I will wear gloves when removing food from the freezer."

Correct Answer is B

Explanation

B) "I will keep my house at a cool temperature": This statement indicates a need for further teaching because maintaining a warm environment is recommended for individuals with Raynaud's phenomenon to prevent vasoconstriction and reduce the risk of attacks. Cold temperatures can trigger symptoms in individuals with this condition. Therefore, advising the client to keep their house warm is appropriate and aligns with preventive measures for Raynaud's phenomenon.

A) "I will try to anticipate and avoid stressful situations": Stress management is an essential aspect of managing Raynaud's phenomenon, as stress can trigger vasospasms. Anticipating and avoiding stressful situations can help reduce the frequency and severity of symptoms.

C) "I will complete the smoking cessation program I started": Smoking cessation is crucial for individuals with Raynaud's phenomenon because smoking narrows blood vessels and exacerbates symptoms. Completing a smoking cessation program is a positive step toward reducing the risk of vasospasms.

D) "I will wear gloves when removing food from the freezer": Wearing gloves when handling cold objects, such as food from the freezer, is recommended for individuals with Raynaud's phenomenon to prevent triggering attacks due to exposure to cold temperatures. This statement demonstrates an understanding of preventive measures for managing the condition.

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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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