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 ["F"]
Explanation
Choice A rationale
A pain rating of 2/10 is not directly related to the therapeutic effect of Bisacodyl. Bisacodyl is a stimulant laxative used to treat constipation, and its effectiveness would not typically be measured by pain ratings20.
Choice B rationale
A non-blanchable red area could be a sign of a pressure ulcer or other skin condition. It is not a therapeutic result of Bisacodyl administration20.
Choice C rationale
Blood pressure of 135/81 mmHg is a normal reading and is not directly related to the therapeutic effect of Bisacodyl20.
Choice D rationale
Sinus tachycardia, or a faster-than-normal heart rate, is not a therapeutic result of Bisacodyl administration. If a patient experiences sinus tachycardia while taking Bisacodyl, they should seek medical attention20.
Choice E rationale
Itching in legs is not a therapeutic result of Bisacodyl administration. It could be a sign of an allergic reaction or other medical condition20.
Choice F rationale
Semifluid stool is the correct answer. Bisacodyl is a stimulant laxative that works by increasing activity in the intestines to cause a bowel movement. Therefore, the production of semifluid stool can be considered a therapeutic result of Bisacodyl administration20.
Choice G rationale
A burning sensation is not a therapeutic result of Bisacodyl administration. If a patient experiences a burning sensation while taking Bisacodyl, they should seek medical attention20.
Correct Answer is D
Explanation
Choice A rationale
Famotidine is a type of medication known as an H2 blocker, which decreases the amount of
acid produced in the stomach. While it can indirectly lead to better sleep by reducing
discomfort, decreased nighttime awakenings is not a direct indicator of its effectiveness.
Choice B rationale
A positive stool antigen test is used to detect the presence of certain bacteria in the
gastrointestinal tract. It is not directly related to the action of famotidine.
Choice C rationale
Weight loss is not a typical result of famotidine use. If a patient experiences significant weight
loss, other causes should be investigated.
Choice D rationale
Famotidine is used to treat conditions like ulcers, gastroesophageal reflux disease (GERD), and
conditions where the stomach produces too much acid, like Zollinger-Ellison syndrome.
Reduced epigastric pain indicates that the medication is effectively reducing stomach acid and
therefore, alleviating symptoms.
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