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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Free Nursing Study Resources

Correct Answer is D

Explanation

The nurse should inform the client that a common side effect of Lisinopril, an ACE inhibitor, is a chronic dry cough. ACE inhibitors can cause irritation in the respiratory tract, leading to a persistent cough. It is important for the client to be aware of this side effect and report it to their healthcare provider if it becomes bothersome.

A. Apply Neosporin to avoid Infection. B. Apply elbow immobilizers when not being held. C. Suction secretions away from the suture line. D. Feed Increased amounts of formula to prevent weight loss.

Correct Answer is C

Explanation

Suctioning secretions away from the suture line helps maintain the surgical site's cleanliness and promotes healing. It helps prevent accumulation of mucus or oral secretions that can interfere with the healing process and increase the risk of infection. The nurse should use a gentle suctioning technique to avoid disrupting the surgical site.

Applying Neosporin to the surgical site is not typically recommended unless specifically prescribed by the healthcare provider. It is important to follow the provider's instructions regarding wound care.

Applying elbow immobilizers when not being held is not necessary for cleft lip surgery. Elbow immobilizers are usually used in other surgical procedures or for other reasons, such as preventing contractures.

Feeding increased amounts of formula to prevent weight loss is not an appropriate intervention for the first few days after cleft lip surgery. The surgical site may be sensitive, and the child may experience difficulty with feeding initially. The nurse should provide guidance and support for feeding techniques appropriate for the child, which may include using specialized bottles or positioning techniques.

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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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Naxlex Comprehensive Predictor Exams

The nurse is providing education to a client who is prescribed Lisinopril (ACE inhibitor) for hypertension. The nurse will be sure to include what information about a common side effect?

Correct Answer is D

Explanation

During the first few days after surgery for cleft lip, which intervention should the nurse implement?

Correct Answer is C

Explanation

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