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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

The best response by the nurse would be to explain that no food or drink is allowed for 4 hours before the stress test.

The reason for this restriction is that consuming food or drink can affect the accuracy of the cardiac stress test results. Eating or drinking can increase heart rate and blood pressure, potentially altering the test's interpretation. It is important for the client to have an empty stomach to ensure accurate test results.

Let's review the other options and explain why they are not the best responses:

Asking the client's visitor to bring some coffee from the cafeteria for the client: This option goes against the restriction of no food or drink before the stress test. It is important to adhere to the guidelines provided to ensure accurate test results.

Making up a small breakfast tray from what is available on the unit: Similarly, providing breakfast to the client goes against the restriction of no food before the stress test. The client should have an empty stomach for the test.

Offering hot tea or coffee only: While hot tea or coffee might be tempting for the client, it still violates the requirement of no food or drink before the stress test. The client should only be allowed to consume water during the fasting period.

A. Document the information as a normal finding B. Prepare the client for an arterial bypass C. Educate the client about the use of compression stocking D. Anticipate a prescription for clopidogrel and simvastatin

Correct Answer is C

Explanation

Based on the information provided, an Ankle-Brachial Index (ABI) of 0.89 indicates a mild reduction in blood flow to the lower extremities, suggesting peripheral arterial disease (PAD). In this case, the nurse should educate the client about the use of compression stockings.

Compression stockings are a conservative management approach for peripheral arterial disease. They help improve blood flow and alleviate symptoms by applying pressure to the legs, promoting venous return, and reducing swelling. Educating the client about the use of compression stockings can help improve circulation and manage symptoms such as pain, cramping, and fatigue.

Let's review the other options and explain why they are not the most appropriate interventions in this scenario:

Document the information as a normal finding: An ABI of 0.89 indicates an abnormal finding suggestive of peripheral arterial disease. It should not be documented as a normal finding, as it requires further assessment and intervention.

Prepare the client for an arterial bypass: An arterial bypass is a surgical intervention that is typically reserved for more severe cases of peripheral arterial disease. With an ABI of 0.89, which indicates mild reduction in blood flow, arterial bypass is not the first-line intervention. Conservative measures and medical management are usually recommended initially.

Anticipate a prescription for clopidogrel and simvastatin: Medications like clopidogrel (antiplatelet) and simvastatin (statin) may be prescribed for peripheral arterial disease. However, the next appropriate step after obtaining an ABI of 0.89 would be to educate the client about the use of compression stockings as a conservative management option before considering medication therapy.

View Question and Answer

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

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 scheduled for a cardiac stress test at 1100. When the nurse enters the client's room at 0800, the client requests toast or at least some coffee. What is the best response?

Correct Answer is A

Explanation

The nurse is assessing a client with a presumptive diagnosis of peripheral arterial disease. The nurse obtains an Ankle-Brachial index of 0.89. Which intervention should the nurse take next?

Correct Answer is C

Explanation

While assessing a client, the nurse notes that the client's ankle-brachial index (ABI) of the right leg is 0.40. How should the nurse best follow up this assessment ﬁnding?

The nurse is assessing a client who has been admitted to the intensive care unit (ICU) with a hypertensive emergency. Which finding is most important to report to the health care provider?

The nurse is providing discharge education to a client who recently have insertion of a pacemaker/ICD. Which statement by the client should require further follow up by the nurse?

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?

The nurse is screening a client prior to an magnetic resonance imaging (MRI). What information is important to report to the health care provider before the MRI?

The nurse is conducting client teaching about cholesterol levels. When discussing the client's elevated LDL and lowered HDL levels, the client shows an understanding of the significance of these levels by making what statement?

The nurse has written a plan of care for a client diagnosed with peripheral arterial insufficiency. Which intervention is the most appropriate for this diagnosis?

The nurse and unlicensed assistive personnel (UAP) are caring for four clients on a telemetry unit. Which nursing task would be best for the nurse to delegate to the UAP?