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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Drink high-protein nutritional supplements between meals: Clients with COPD often experience anorexia due to fatigue, difficulty breathing while eating, and early satiety. High-protein, high-calorie supplements between meals help meet nutritional needs without overwhelming them during main meals, supporting energy levels and respiratory muscle strength.

B. Eat more hot foods than cold foods at mealtime: Hot foods can produce stronger odors that may worsen appetite loss. Cold foods tend to have milder smells and may be better tolerated by clients with anorexia, making cold foods preferable rather than focusing on hot foods.

C. Eat low-calorie foods first at mealtime: Clients with anorexia and COPD should prioritize high-calorie, nutrient-dense foods first to maximize intake before feeling full. Eating low-calorie foods first could reduce overall calorie intake, worsening weight loss and malnutrition risks.

D. Increase liquids during meals: Consuming large amounts of liquid during meals can cause early satiety, making it harder for clients to consume enough food. It is better to encourage drinking fluids between meals to optimize food intake during eating times.

A. Monitor the client for 1 hr after meals B. Allow the client 2 hrs to finish meals. C. Weigh the client every 2 days. D. Check the client's vital signs two times per week.

Correct Answer is A

Explanation

A. Monitor the client for 1 hr after meals: Clients with anorexia nervosa are at high risk for purging behaviors such as vomiting or excessive exercise after meals. Monitoring them for at least 1 hour post-meal helps prevent these behaviors and supports the therapeutic goal of safe weight restoration.

B. Allow the client 2 hr to finish meals: Allowing 2 hours to complete meals is too long and may encourage food avoidance behaviors. Structured meal times with limits (usually around 30 to 45 minutes) are important to establish routine eating habits and prevent manipulation of eating times.

C. Weigh the client every 2 days: Clients with anorexia nervosa are typically weighed daily, often at the same time each morning, to closely monitor weight trends and assess the effectiveness of the treatment plan. Monitoring every 2 days may miss rapid changes that require immediate intervention.

D. Check the client's vital signs two times per week: Vital signs should be checked daily in clients with anorexia nervosa, especially early in treatment, because of the risks of bradycardia, hypotension, and hypothermia. Infrequent monitoring can delay recognition of life-threatening physiological instability.

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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?

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