A nurse is administering nicardipine to a client who has a BP of 180/120 mm Hg. Which of the following actions should the nurse take first?

Check for orthostatic hypertension.

Assist the client to make lifestyle changes.

Instruct the client to restrict sodium intake.

Monitor the client's BP every 5 minutes.

Answer and Explanation

The Correct Answer is D

A. Check for orthostatic hypotension. While important, checking for orthostatic hypotension is not the priority action in a hypertensive emergency, where rapid blood pressure reduction is necessary.

B. Assist the client to make lifestyle changes. Assisting the client with lifestyle changes is part of long-term blood pressure management but is not a priority action when administering nicardipine for acute hypertension.

C. Instruct the client to restrict sodium intake. Sodium restriction is a key component of managing hypertension but is not the priority action during an acute hypertensive crisis.

D. Monitor the client's BP every 5 minutes. In a hypertensive crisis, frequent monitoring of the client’s blood pressure is essential to ensure the medication is lowering blood pressure safely and effectively.

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Correct Answer is B

Explanation

A. Liver: Liver is high in cholesterol and should be avoided by clients on a low-cholesterol diet. This is not a suitable choice for the client.

B. Beans: Beans are a high-fiber, plant-based protein source that is low in cholesterol. This is a good choice for a low-cholesterol diet.

C. Eggs: Eggs contain cholesterol, particularly in the yolk. While one egg a day may be acceptable for some individuals, this is generally a food that should be limited on a low-cholesterol diet.

D. Milk: Depending on the fat content, milk can be high in cholesterol. Clients should opt for skim or low-fat milk to reduce cholesterol intake. Full-fat milk is not ideal for a low-cholesterol diet.

A. Elevate the head of the bed 45 degrees. B. Limit fluid intake for 4 hr after the procedure. C. Have the client rest in bed for 2 hr. D. Insert an indwelling urinary catheter 1 hr post procedure.

Correct Answer is C

Explanation

A. Elevate the head of the bed 45 degrees. The head of the bed should not be elevated this high, as this can increase pressure on the arterial access site, risking bleeding or disruption of the closure device.

B. Limit fluid intake for 4 hr after the procedure. Fluids should actually be encouraged to help flush out contrast dye used during the procedure and to maintain hydration. Limiting fluids could increase the risk of renal complications.

C. Have the client rest in bed for 2 hr. Bed rest is typically required after cardiac catheterization, especially with the use of an arterial closure device. Two hours is a reasonable time for initial bed rest following the procedure.

D. Insert an indwelling urinary catheter 1 hr post procedure. A urinary catheter is not routinely required after a cardiac catheterization unless there are specific medical indications.

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A nurse is administering nicardipine to a client who has a BP of 180/120 mm Hg. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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