During a health screening, a patient's blood pressure is confirmed by two clinic nurses to be 220/120 mm Hg. Which of the following actions should the nurse recommend to the patient?
“Take off work for the rest of the day to rest at home."
"Return to work and have your blood pressure rechecked in 2 days."
"Take two doses of blood pressure medication right now."
"Sit quietly while we call 911 to request an ambulance."
The Correct Answer is D
A. “Take off work for the rest of the day to rest at home.": This advice is not adequate for such a high blood pressure reading, which indicates a hypertensive crisis that requires immediate medical intervention.
B. "Return to work and have your blood pressure rechecked in 2 days.": This is inappropriate as it delays necessary urgent medical evaluation and treatment.
C. "Take two doses of blood pressure medication right now.": Without medical supervision, this could be dangerous and is not appropriate in an emergency situation where the blood pressure is critically high.
D. "Sit quietly while we call 911 to request an ambulance.": A blood pressure of 220/120 mm Hg suggests a hypertensive emergency, which can lead to life-threatening complications like stroke or heart attack. The patient needs immediate medical attention, and calling 911 is the appropriate response.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is B
Explanation
A. I will be sure to avoid potassium while taking this medication.: Thiazide diuretics can cause potassium loss, so patients are often advised to monitor their potassium levels and may need to increase their intake, not avoid it.
B. I should take the medication in the morning so I am not up all night going to the bathroom.: This is correct. Taking diuretics in the morning helps prevent nocturia (frequent urination at night), which can disrupt sleep.
C. I need to be sure to take this pill on an empty stomach.: Thiazide-like diuretics do not require an empty stomach for effectiveness; they can be taken with or without food.
D. If my blood pressure is really high, I will take a second dose.: This is incorrect and potentially dangerous. Medication dosing should be followed as prescribed, and adjustments should only be made by a healthcare provider.
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