The nurse is caring for a client in a hypertensive emergency. Which action will be included in the plan of care during hypertensive emergency who is receiving nifedipine?

Organize nursing activities so that the patient has 8 hours of undisturbed sleep at night.

Use an automated noninvasive blood pressure machine to obtain frequent measurements.

Keep the hypertensive emergency NPO to prevent aspiration caused by nausea and possible vomiting.

Assist the patient up in the chair for meals to avoid complications associated with immobility.

Answer and Explanation

The Correct Answer is B

The action that will be included in the plan of care for a client in a hypertensive emergency receiving nifedipine is to use an automated noninvasive blood pressure machine to obtain frequent measurements.

In a hypertensive emergency, the client's blood pressure is severely elevated, requiring immediate treatment and close monitoring. Nifedipine is a calcium channel blocker commonly used to lower blood pressure in such situations. Continuous blood pressure monitoring is crucial to assess the effectiveness of the medication and ensure that the blood pressure is brought under control safely.

Organize nursing activities so that the patient has 8 hours of undisturbed sleep at night: While providing a conducive environment for sleep is important for overall patient well-being, in a hypertensive emergency, the priority is to manage and monitor the blood pressure. Sleep hygiene may not be the immediate concern in this situation.

Keep the hypertensive emergency NPO to prevent aspiration caused by nausea and possible vomiting: NPO (nothing by mouth) orders are typically implemented when there is a risk of aspiration or pending a procedure requiring anesthesia. In a hypertensive emergency, the focus is on managing blood pressure and ensuring appropriate hydration and nutrition as needed. NPO status may not be necessary unless speciﬁcally indicated for the individual patient.

Assist the patient up in the chair for meals to avoid complications associated with immobility: While mobilization and preventing complications associated with immobility are important aspects of care, in a hypertensive emergency, the primary focus is on managing blood pressure and stabilizing the client's condition. Mobilization may be appropriate once the blood pressure is under control and the client's condition permits.

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Correct Answer is A

Explanation

The information that the nurse should include in the teaching plan for a client with hypertension who is on alpha blockers and at risk for postural hypotension is: Change positions slowly.

Alpha blockers are a class of medications commonly prescribed for hypertension. One potential side effect of alpha blockers is postural hypotension, which is a sudden drop in blood pressure when changing positions, such as from sitting to standing. To minimize the risk of postural hypotension, it is important for the client to change positions slowly. The nurse should advise the client to take their time when transitioning from lying down, sitting, or standing, allowing their body to adjust and stabilize their blood pressure.

The other options are not appropriate or helpful in managing postural hypotension:

Check blood pressure every day for signs of rebound hypertension: Rebound hypertension refers to a sudden increase in blood pressure that can occur when discontinuing certain antihypertensive medications. It is not directly related to postural hypotension. Regular blood pressure monitoring is important for managing hypertension, but it is not specifically related to postural hypotension or alpha blockers.

Do not become dependent on canes, walkers, or handrails: Assistive devices like canes, walkers, or handrails can provide support and stability for individuals who experience balance issues or are at risk of falls. It is not necessary to discourage their use unless there are specific contraindications or safety concerns.

Eat plenty of salty food to prevent hypotension: Increasing salt intake is generally not recommended for individuals with hypertension or those at risk of postural hypotension. A high-sodium diet can contribute to elevated blood pressure and is generally discouraged. The nurse should instead encourage a balanced diet that includes appropriate sodium intake based on the client's healthcare provider's recommendations.

A. Obtain consent for transesophageal echocardiogram (TEE) B. Obtain consent for a STAT defibrillation C. Obtain consent for cardioversion. D. Hold digoxin 48 hours prior to cardioversion.

Correct Answer is B

Explanation

Defibrillation is not the first-line treatment for atrial fibrillation. It is used to treat life-threatening cardiac arrhythmias such as ventricular fibrillation or pulseless ventricular tachycardia. Atrial fibrillation, on the other hand, is a rapid and irregular atrial rhythm, and defibrillation is not indicated for its treatment.

Obtain consent for transesophageal echocardiogram (TEE): This is an appropriate action for a client with atrial fibrillation. A TEE is often performed to assess the structure and function of the heart in cases of atrial fibrillation, especially when considering cardioversion or other interventions.

Obtain consent for cardioversion: Cardioversion is a common treatment option for atrial fibrillation, especially when the client is unstable or experiencing symptoms. It involves restoring a normal heart rhythm through the use of electrical shocks or medications. It is important to obtain informed consent before performing cardioversion, but this does not necessarily require questioning.

Hold digoxin 48 hours prior to cardioversion: Digoxin is commonly held before cardioversion because it can increase the risk of certain arrhythmias during the procedure. This is a standard precaution to minimize potential adverse effects. Therefore, the nurse does not need to question this action, as it aligns with established guidelines.

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The nurse is caring for a client in a hypertensive emergency. Which action will be included in the plan of care during hypertensive emergency who is receiving nifedipine?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with hypertension who is on alpha blockers. The nurse is concerned about postural hypotension. Which information should the nurse include in the teaching plan?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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