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
Heart rate is an important vital sign to monitor in patients, but it is not the primary outcome
data to prioritize when administering a 20% mannitol intravenous (IV) solution. Mannitol is a diuretic that works by increasing the amount of urine produced. Therefore, while heart rate can be affected by fluid balance changes, it is not the most directly relevant outcome to monitor in this context.
Choice B rationale
Ankle circumference could be an indicator of peripheral edema, which might suggest fluid
overload or poor kidney function. However, in the context of mannitol administration, which is a diuretic and would be expected to decrease fluid overload, ankle circumference is not the primary outcome to monitor.
Choice C rationale
Urinary output is the correct answer. Mannitol is an osmotic diuretic that increases urine
production. It is used to reduce intracranial and intraocular pressure by drawing water out of tissues and into the bloodstream, from where it can be excreted by the kidneys. Therefore, urinary output is the most direct measure of its effectiveness and is the key outcome that should be monitored.
Choice D rationale
Dietary intake is always important to monitor in patients, especially those receiving IV
therapy, as it can impact electrolyte balance and overall health status. However, it is not the primary outcome to monitor when administering mannitol.
Correct Answer is A
Explanation
Choice A rationale
Clearing the nose with a tissue prior to the instillation of nasal drops can help to remove
mucus and other obstructions, allowing the medication to reach the nasal passages more
effectively15.
Choice B rationale
Deep inhalation through the nose is not typically recommended prior to the instillation of
nasal drops. It could potentially draw the medication deeper into the nasal passages or into the
throat, rather than allowing it to remain in the intended area15.
Choice C rationale
Holding the breath temporarily is not typically necessary or recommended prior to the
instillation of nasal drops15.
Choice D rationale
the nasal passages, but it is not as effective or recommended as using a tissue to clear the
nose15.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.