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 ["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.
Correct Answer is B
Explanation
Choice A rationale
Encouraging the patient to share his concerns about the care plan is important, but it does not directly address the patient’s question about why his temperature is being taken.
Choice B rationale
Promethazine is a medication that can cause a variety of side effects, including changes in body temperature. Therefore, monitoring the patient’s temperature can help assess for potential side effects of the medication. This is the most direct and relevant response to the patient’s question.
Choice C rationale
While it’s true that vital signs are often taken routinely, this does not specifically address why the patient’s temperature is being taken in this particular instance, four hours after
administering promethazine.
Choice D rationale
While promethazine can affect body temperature, it is not primarily used to lower body
temperature. Therefore, explaining that the medication works to lower body temperature may not be entirely accurate or relevant in this context.
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