A nurse is caring for a client who has severe hypertension and is to receive nitroprusside via continuous IV infusion.
Which of the following actions should the nurse plan to take?

Keep calcium gluconate at the client's bedside.

Attach an inline filter to the IV tubing.

Protect the IV bag from exposure to light.

Monitor blood pressure every 2 hr.

Answer and Explanation

The Correct Answer is C

Answer is: c. Protect the IV bag from exposure to light.

Explanation: Nitroprusside degrades when exposed to light, so the nurse should protect the IV bag from light exposure to maintain the medication's potency and effectiveness in treating the client's severe hypertension.

Choice a. is wrong because calcium gluconate is used as an antidote for magnesium sulfate toxicity. Although it may be kept on hand in some facilities, it is not directly related to the administration of nitroprusside.

Choice b. is wrong because attaching an inline filter is not necessary when administering nitroprusside. It is more relevant for medications that require filtration, such as certain chemotherapeutic agents.

Choice d. is wrong because monitoring blood pressure every 2 hours is not frequent enough for a client receiving nitroprusside. The nurse should monitor the client's blood pressure more frequently, such as every 5 to 15 minutes, depending on facility policies and the client's condition.

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Correct Answer is B

Explanation

The correct answer is choice B: Wear a surgical mask when within 0.9 m (3 feet) of the client.

Choice A rationale:

Fresh flowers are generally discouraged in hospital settings for clients with compromised immune systems due to the risk of infection from soil or water, which can harbor harmful microorganisms. However, this is not specifically related to rubella, which is an airborne virus.

Choice B rationale:

Rubella is transmitted through airborne droplets when an infected person coughs or sneezes. Wearing a surgical mask when close to the client can help prevent the spread of the virus. This is especially important to protect individuals who are pregnant or may become pregnant, as rubella can cause serious birth defects.

Choice C rationale:

Negative-airflow pressure rooms are used for clients with airborne infections, such as tuberculosis. While rubella is also airborne, the current guidelines do not require a negative pressure room for its management.

Choice D rationale:

While limiting visitors can help control the spread of infection, it is not the primary action to take for a client with rubella. The focus should be on preventing the spread through droplet transmission, which is addressed by wearing a mask and practicing good hand hygiene.

A. Tie a tourniquet around the leg distal to the wound. B. Irrigate the wound with sterile water. C. Apply direct pressure to the wound with thick dressing material. D. Apply a transparent dressing to the wound.

Correct Answer is C

Explanation

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A nurse is caring for a client who has severe hypertension and is to receive nitroprusside via continuous IV infusion. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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A nurse is caring for a client who has severe hypertension and is to receive nitroprusside via continuous IV infusion.
Which of the following actions should the nurse plan to take?