A nurse is caring for a client on a medical-surgical unit. Which intervention should the nurse prioritize?
Monitoring blood pressure trends after administering antihypertensive medication.
Administering prescribed Potassium Chloride 20 mEq PO STAT.
Reassessing the client for additional medication needs at 1300.
Educating the client about the importance of maintaining stable blood pressure levels.
The Correct Answer is B
Choice A rationale
Monitoring blood pressure trends ensures early detection of medication effectiveness, yet is secondary to addressing critical hypokalemia. Normal blood pressure is 120/80 mmHg; deviations warrant monitoring, but this is not the priority intervention.
Choice B rationale
Administering potassium chloride STAT addresses potential hypokalemia, which risks arrhythmias and muscle weakness. Normal potassium levels range between 3.5-5.0 mEq/L, highlighting urgency when potassium is below normal.
Choice C rationale
Reassessing additional medication needs at a set time ensures comprehensive care but does not address immediate life-threatening conditions like hypokalemia, which requires urgent correction to prevent cardiac dysfunction.
Choice D rationale
Educating about blood pressure maintenance is crucial for long-term management but does not address the immediate physiological imbalance or risk of arrhythmias due to electrolyte disturbance, making it a lower priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Orange slices pose a choking risk due to their firm texture and fibrous membranes, making them inappropriate for a mechanical soft diet.
Choice B rationale
Ground hamburger has a soft consistency and is easily chewable, meeting the requirements of a mechanical soft diet.
Choice C rationale
Cooked green beans are soft and easy to chew, aligning with the dietary restrictions of a mechanical soft diet.
Choice D rationale
Canned peaches are soft and can be mashed easily, making them suitable for a mechanical soft diet.
Correct Answer is D
Explanation
Choice A rationale
Soft stools do not directly indicate enteral feeding intolerance, as this consistency is a normal variation in stool formation and does not signify gastrointestinal complications like vomiting, nausea, or diarrhea.
Choice B rationale
A urine output of 40 mL/hr signifies oliguria, potentially due to dehydration or renal impairment, but is unrelated to enteral feeding tolerance. Enteral feedings mainly affect gastrointestinal parameters.
Choice C rationale
Headache is a nonspecific symptom influenced by multiple factors, such as hydration status or systemic illnesses, rather than indicating enteral feeding intolerance directly.
Choice D rationale
A residual volume greater than 250 mL suggests delayed gastric emptying, increasing the risk of aspiration. This finding is a key indicator of enteral feeding intolerance requiring intervention.
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