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 C
Explanation
A. Encourage visits from family members: While family presence can help reduce anxiety and reorient clients with delirium, it is not the immediate first step. Before implementing supportive strategies, the nurse must first assess the client’s neurological status to determine the severity and possible cause of the delirium.
B. Administer an anxiolytic medication: Administering medications should not be the first action because delirium can be caused by multiple reversible factors. Sedating a client without identifying the underlying cause may worsen confusion or mask important symptoms that need immediate intervention.
C. Determine the client's level of consciousness: Assessing the client’s level of consciousness is the priority because it provides critical information about the severity of the delirium and helps guide immediate and appropriate interventions. Early assessment ensures that life-threatening conditions, such as hypoxia or sepsis, are not overlooked.
D. Keep lights on in the client's room: Maintaining a well-lit environment can help prevent disorientation, especially at night, but it is a secondary supportive measure. Assessment of mental status must occur first to prioritize safety and identify urgent medical needs.
Correct Answer is D
Explanation
A. WBC count 12,000/mm³: A mild elevation in white blood cell count is expected within the first few days postpartum as part of the normal inflammatory response due to the stress of labor and delivery.. A count of 12,000/mm³ is not alarming and does not necessarily indicate infection or a complication.
B. Temperature 37.8°C (100°F): A low-grade temperature elevation within the first 24 hours postpartum is common due to hormonal shifts, dehydration, or exertion from labor. This finding would not immediately require provider notification unless it persists or rises higher.
C. Respiratory rate 16/min: A respiratory rate of 16 breaths per minute is within normal adult limits and does not suggest respiratory distress or any postpartum complication, so no intervention is required for this finding.
D. Hgb 8 g/dL: A hemoglobin level of 8 g/dL is significantly low and can indicate postpartum hemorrhage or significant blood loss. This degree of anemia should be reported promptly to the provider to assess the need for interventions such as blood transfusion or iron supplementation.
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