A nurse is caring for a client who has chronic kidney failure. An assistive personnel reports that the client has a blood pressure of 190/110mm Hg. Which of the following actions should the nurse take first?
Report the blood pressure reading to the charge nurse.
Administer an antihypertensive medication.
Remeasure the client's blood pressure.
Instruct the client to remain in bed.
The Correct Answer is C
A. Report the blood pressure reading to the charge nurse: While notifying the charge nurse is important, the nurse should first validate the high reading by rechecking the blood pressure. Acting on a single, unverified reading could lead to unnecessary interventions or missed opportunities for accurate assessment.
B. Administer an antihypertensive medication: Administering antihypertensive medication based solely on a report without rechecking the blood pressure could be unsafe. Verification ensures that treatment is based on accurate clinical data and prevents unnecessary medication administration.
C. Remeasure the client's blood pressure: The first action should always be to recheck an unusually high or abnormal vital sign reading to confirm its accuracy. Errors can occur during measurement, and accurate confirmation is critical before proceeding with further interventions in a client with chronic kidney failure.
D. Instruct the client to remain in bed: While keeping the client in bed can help prevent complications if severe hypertension is confirmed, it is not the priority action. Verifying the blood pressure reading must occur first to determine the appropriate course of action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. BMI 32: A BMI of 30 or higher indicates obesity, which is a major risk factor for developing type 2 diabetes mellitus. Excess body fat, especially abdominal fat, contributes to insulin resistance, increasing the likelihood of diabetes.
B. Alcohol use: While excessive alcohol intake can affect overall health, moderate alcohol consumption is not a primary direct risk factor for type 2 diabetes. Other factors like obesity and sedentary lifestyle have a stronger association.
C. Age 35 years: Advancing age increases diabetes risk, but significant age-related risk typically rises after age 45. At 35 years old, age alone is not considered a major risk factor without additional contributing conditions.
D. Medical history of asthma: Asthma is a chronic respiratory condition but is not recognized as a risk factor for type 2 diabetes mellitus. The primary risk factors involve metabolic, genetic, and lifestyle components rather than respiratory history.
Correct Answer is B
Explanation
A: Image A shows a newborn wrapped in a blanket with generalized redness on the face but without distinct blotchy areas or pustules. This appearance is more consistent with normal transitional skin changes such as acrocyanosis or overall mild skin redness after birth. It does not match the appearance of erythema toxicum.
B: Image B shows a close-up of the newborn’s face with visible small red blotchy spots, especially around the cheeks and nose. This matches the classic presentation of erythema toxicum, a benign newborn rash appearing within the first 24 hours. It is characterized by red patches with possible small pustules scattered over the face and body.
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