A patient with a history of hypertension arrives in the emergency department with a blood pressure (BP) reading of 213/126 mm Hg. The patient has a history of drug abuse.

Which of the following initial questions posed by the nurse is MOST appropriate?.

"Did you take any Tylenol today?".

"Have there been recent stressful events in your life?".

"Have you recently taken any cocaine or crack?".

"Have you eaten any salty foods lately?". .

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Tylenol, or acetaminophen, is a common over-the-counter medication used to reduce fevers and manage mild aches and pains. It does not directly affect blood pressure.

Choice B rationale:

While stress can cause temporary spikes in blood pressure, it’s not clear whether stress can cause long-term increases in blood pressure34.

Choice C rationale:

Cocaine or crack use can cause a significant and dangerous increase in blood pressure. Given the patient’s history of drug abuse and the current high blood pressure reading, this is a critical question to ask.

Choice D rationale:

Eating salty foods can contribute to high blood pressure over time, but it’s unlikely to cause an immediate severe increase in blood pressure.

So, the correct answer is Choice C, after analyzing all choices. .

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Correct Answer is B

Explanation

Choice A rationale:

A brief episode of ventricular tachycardia, or a rapid heart rate, can occur in patients receiving thrombolytic therapy. However, it is not typically a reason to stop the drug infusion.

Choice B rationale:

Bleeding from the gums can be a sign of excessive bleeding, which is a major risk of thrombolytic therapy. This would be a reason to stop the drug infusion.

Choice C rationale:

A decreased level of consciousness can have many causes and is not specifically associated with thrombolytic therapy.

Choice D rationale:

An increase in blood pressure is not typically a reason to stop thrombolytic therapy.

So, the correct answer is B, after analyzing all choices.

A. Temperature. B. Oxygen saturation. C. Blood pressure. D. Weight. E. Urine output. F. Breath sounds.

Correct Answer is ["B","C","D","F"]

Explanation

Choice A rationale:

The client’s temperature decreased from 37.6°C to 36.8°C1. This is within the normal body temperature range of 36.5°C to 37.2°C2, so it does not require further action.

Choice B rationale:

The client’s oxygen saturation decreased from 95% to 88%1. Normal pulse oximetry values are typically above 95%2. This decrease could indicate that the client is not getting enough oxygen, which requires further action.

Choice C rationale:

The client’s blood pressure increased from 108/50 mm Hg to 138/80 mm Hg. Normal blood pressure for adults is below 120/80 mm Hg. This increase could indicate worsening heart failure, which requires further action.

Choice D rationale:

The client’s weight increased from 80 kg to 82.1 kg. Rapid weight gain may be a sign of fluid retention, a common symptom of heart failure. This requires further action.

Choice E rationale:

The client’s urine output decreased from 480 mL/8 hr to 320 mL/8 hr.However it is still above 30ml/hr signifying normal renal function

Choice F rationale:

On Day 4, the client’s breath sounds were scattered, and crackles were heard bilaterally. This could indicate fluid accumulation in the lungs, a common symptom of heart failure. This requires further action.

So, the correct answer is Choices B, C, D, and F, after analyzing all choices.

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A patient with a history of hypertension arrives in the emergency department with a blood pressure (BP) reading of 213/126 mm Hg. The patient has a history of drug abuse. Which of the following initial questions posed by the nurse is MOST appropriate?.

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Naxlex Comprehensive Predictor Exams

The nurse is administering a thrombolytic agent to a patient having an acute myocardial infarction. Which patient data indicates that the nurse should stop the drug infusion?.

Correct Answer is B

Explanation

Correct Answer is ["B","C","D","F"]

Explanation

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A patient with a history of hypertension arrives in the emergency department with a blood pressure (BP) reading of 213/126 mm Hg. The patient has a history of drug abuse.

Which of the following initial questions posed by the nurse is MOST appropriate?.