Client Data

Exhibits

The LPN/LVN determines that the patient is in hypertensive urgency crisis and that his blood pressure will need to be lowered slowly. The nurse is also concerned that the blood pressure is elevated while the patient is on antihypertensives. Which additional information would be most important for the nurse to collect from the patient?

Has the patient been taking his medications as prescribed?

Does the patient hurt anywhere else?

When does the patient take his furosemide?

Has the patient fallen before?

Answer and Explanation

The Correct Answer is D

Has the patient been taking his medications as prescribed? This is the most important information to collect. Understanding the patient's medication adherence is crucial because if the patient is not taking his medications as prescribed, it could explain why his blood pressure is elevated. Noncompliance with medication regimens is a common cause of hypertensive urgency and can lead to severe complications. Therefore, knowing whether he has been taking his medications regularly and correctly would directly influence the management plan and help identify the cause of the current crisis.

Does the patient hurt anywhere else? While it’s important to assess for pain and discomfort to address immediate symptoms, this information does not directly address the potential cause of the elevated blood pressure. The patient already reported pain in the head, chest, and left leg, so the primary concern is managing his hypertensive urgency and understanding its underlying causes rather than identifying additional pain locations at this moment.

When does the patient take his furosemide? Knowing the timing of furosemide intake could provide insights into his diuretic therapy management and its potential impact on his blood pressure. However, it is less immediately relevant than understanding whether he has been taking all his medications as prescribed. This question might be more pertinent once medication adherence is confirmed to understand diuretic effects throughout the day.

Has the patient fallen before? This is relevant for assessing the risk of recurrent falls and potential underlying issues such as orthostatic hypotension or balance problems, which are crucial for long-term management and safety. However, it is not as immediately critical in the context of the current hypertensive urgency and the elevated blood pressure despite medication.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A. Calcium 9.4 mg/dL: This is within the normal range for calcium (8.5-10.2 mg/dL), so it is not a concern.
B. Sodium 140 mEq/L: This value is within the normal range for sodium (135-145 mEq/L), so it is not a concern.
C. Potassium 2.5 mEq/L: This is below the normal range for potassium (3.5-5.0 mEq/L) and indicates hypokalemia, which is a common side effect of furosemide, a diuretic. Hypokalemia can cause serious cardiac issues and requires prompt attention.
D. Magnesium 1.9 mEq/L: This is within the normal range for magnesium (1.5-2.5 mEq/L), so it is not a concern.

A. Assist the patient to turn to her side. B. Give an antiemetic as ordered. C. Perform a test for blood on the emesis. D. Call for an aide to get suction set up.

Correct Answer is A

Explanation

A. Assist the patient to turn to her side: This is the priority action to prevent aspiration of vomitus, which can be a serious complication for stroke patients who may have impaired swallowing and a reduced gag reflex.
B. Give an antiemetic as ordered: While important, administering an antiemetic should come after ensuring the patient’s safety and preventing aspiration.
C. Perform a test for blood on the emesis: This is not the immediate priority. Preventing aspiration is the first concern.
D. Call for an aide to get suction set up: Suction may be necessary if the patient is at risk of aspiration, but the first step is to turn the patient to prevent choking and aspiration.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is reviewing lab values for a patient taking furosemide. Which of these lab values would concern the nurse?

Correct Answer is C

Explanation

The nurse is caring for a patient recently admitted with a stroke. The patient is experiencing nausea and begins to vomit. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

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