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 A
Explanation
Choice A rationale
If a patient’s pain level remains high despite receiving regular doses of fentanyl, it may indicate
that the current dose is insufficient. The PN should report this to the healthcare provider, who
may decide to increase the dose.
Choice B rationale
While it’s important to continue monitoring the patient and assessing the pain level, this alone
may not be sufficient if the patient’s pain remains uncontrolled.
Choice C rationale
Non-pharmacological methods of pain control can be beneficial, but they are typically used in
conjunction with medication, not as a replacement for it when the pain level is high.
Choice D rationale
Informing the patient about the potential addictiveness of the medication is important, but it’s
not the most appropriate action to take in response to uncontrolled pain.
Correct Answer is ["1"]
Explanation
Step 1 is: Calculate the total amount of warfarin required. The healthcare provider has prescribed 7.5 mg of warfarin.
Step 2 is: Subtract the amount of warfarin already administered. The patient has already received 2 tablets, each containing 2.5 mg of warfarin, for a total of 5 mg.
Step 3 is: Calculate the additional amount of warfarin required. The total amount required (7.5 mg) minus the amount already administered (5 mg) equals 2.5 mg.
Step 4 is: Determine the number of additional tablets required. Since each tablet contains 2.5 mg of warfarin, the patient should receive 1 additional tablet.
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