The nurse is administering nitroprusside by IV infusion for a client in hypertensive emergency. The nurse knows that the primary assessment will be:

Blood pressure due to the vasoconstriction action of this medication.

Intake/output due to the diuretic action of this medication.

Blood pressure due to the vasodilation action of this medication.

Peripheral pulses due to the vasoconstriction action of this medication.

Answer and Explanation

The Correct Answer is C

Nitroprusside is a potent vasodilator medication used to rapidly reduce blood pressure in hypertensive emergencies. Its primary action is to dilate blood vessels, leading to a decrease in systemic vascular resistance and subsequent reduction in blood pressure.

Monitoring the client's blood pressure is crucial during the administration of nitroprusside to ensure that the medication is achieving the desired effect and that blood pressure is being appropriately controlled. The nurse will assess blood pressure frequently to adjust the infusion rate and titrate the medication to achieve the desired therapeutic effect while avoiding hypotension or other adverse effects.

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Correct Answer is A

Explanation

After spinal fusion surgery, it is important to limit the patient's activity and movement to allow for proper healing and to prevent complications. The order to have the patient out of bed three times daily and ad lib (as desired) is not appropriate immediately after surgery.

The other orders listed are appropriate for the postoperative care of a patient who has undergone spinal fusion surgery:

Assess neurological status every 4 hours: This is important to monitor for any changes in neurological function, which could indicate complications such as nerve damage or spinal cord compression.
Logroll only to change position: Logrolling is a technique used to move patients with spinal fusion surgery while keeping their spine aligned and minimizing stress on the surgical site. This order is appropriate to ensure proper positioning and prevent injury to the surgical area.
Monitor vital signs every 4 hours: Monitoring vital signs helps to assess the patient's overall condition and detect any signs of complications such as bleeding or infection.

A. Explain procedures and routines. B. Provide for privacy. C. Encourage the parents to room in. D. Encourage contact with children the same age.

Correct Answer is C

Explanation

Toddlers often experience separation anxiety when separated from their primary caregivers. Having the parents stay with the child in the hospital, commonly known as rooming in, can provide a sense of security and familiarity, which helps alleviate separation anxiety. It allows the child to have a consistent presence and promotes a nurturing and comforting environment.

While explaining procedures and routines can be helpful, it may not fully address the underlying separation anxiety experienced by the toddler. Providing for privacy and encouraging contact with children the same age may not directly address the primary source of anxiety, which is being separated from the parents.

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The nurse is administering nitroprusside by IV infusion for a client in hypertensive emergency. The nurse knows that the primary assessment will be:

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The nurse is caring for an adolescent diagnosed with scoliosis who just arrived to the floor from the recovery room after a Spinal fusion surgery. The nurse should question which physician order?

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Correct Answer is C

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