The client’s heart rate is 96 beats per minute, blood pressure is 220/129 mmHg, and respiratory rate is 18 breaths per minute.
The client is complaining of a headache. Ibuprofen was given as ordered.
Furosemide 50 mg IV was also given.
What should be the next step in the client’s care?
Attach the client to a continuous cardiac monitor
Place an indwelling urinary catheter
Give a fluid bolus
Draw a basic metabolic panel (BMP)
The Correct Answer is A
Choice A rationale
Given the client’s high blood pressure and complaint of a headache, it is important to continuously monitor the client’s cardiac status to detect any changes that may indicate worsening condition.
Choice B rationale
Placing an indwelling urinary catheter is not the immediate next step in this client’s care. While it may be necessary in some cases, it is not directly related to the client’s current symptoms.
Choice C rationale
Giving a fluid bolus is not the immediate next step in this client’s care. While it may be necessary in some cases, it is not directly related to the client’s current symptoms.
Choice D rationale
Drawing a basic metabolic panel (BMP) could be helpful in assessing the client’s overall health and kidney function, but it is not the immediate next step in this client’s care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Headaches are a common side effect of many medications and do not necessarily indicate a serious problem. However, if the headache is severe or persistent, it should be reported to the healthcare provider.
Choice B rationale
Difficulty sleeping is not typically associated with propranolol. While it can occur, it is not a common side effect and is not usually a cause for concern.
Choice C rationale
Palpitations, or a feeling of a fast, fluttering, or pounding heart, can be a sign of an irregular heartbeat, which can be a serious side effect of propranolol. This is because propranolol is a beta-blocker, a type of drug that can slow heart rate and reduce the force of heart contractions. Therefore, if a patient reports palpitations, the healthcare provider should be notified before the next dose of propranolol is given.
Choice D rationale
Nausea is a common side effect of many medications, including propranolol. However, it is usually mild and temporary. If the nausea is severe, persistent, or accompanied by other symptoms such as vomiting, the healthcare provider should be notified.
Correct Answer is A
Explanation
Choice A rationale
If a child undergoing a blood transfusion complains of itchy skin and appears flushed, these
could be signs of a transfusion reaction. The PN should stop the transfusion immediately.
Choice B rationale
While inspecting the infusion site is a part of regular monitoring during a transfusion, it would
not typically be the first action in response to symptoms of a possible transfusion reaction.
Choice C rationale
Applying lotion to the skin would not address the underlying issue if the child is experiencing a
transfusion reaction.
Choice D rationale
Checking the vital signs is important, but the first action should be to stop the transfusion if a
reaction is suspected.
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