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 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.

A. The need to take anticoagulants concurrent with using compression stockings B. The need to wear the stockings on a one day on, one day off schedule C. The importance of wearing the stockings around the clock to ensure maximum benefit D. The importance of ensuring the stockings are applied evenly with no pressure points

Correct Answer is D

Explanation

The importance of ensuring the stockings are applied evenly with no pressure points: Compression stockings are designed to provide graduated pressure to the legs, helping improve blood flow and reduce swelling in individuals with venous insufficiency. It is crucial for the client to understand how to properly apply the stockings to maximize their effectiveness and prevent any complications. The nurse should emphasize the following points:

● Ensure the stockings are applied evenly: The stockings should be applied smoothly and evenly without any folds or wrinkles. This helps ensure that the pressure is distributed uniformly, enhancing their therapeutic effect.

● Check for pressure points: The client should be instructed to pay attention to any areas where the stockings may be causing excessive pressure or discomfort. Pressure points can impair circulation or cause skin damage. If pressure points are noticed, adjustments should be made to ensure proper fit and comfort.

● Follow manufacturer's instructions: The nurse should provide specific instructions regarding how to correctly don the compression stockings, including any specific guidelines provided by the manufacturer. This may include recommendations for the time of day to apply the stockings or any specific donning techniques.

The other options mentioned in the question are not essential information for the teaching plan:

The need to take anticoagulants concurrent with using compression stockings: While some individuals with venous insufficiency may require anticoagulant therapy, it is not directly related to the use of compression stockings. Anticoagulant therapy is typically prescribed for other reasons, such as prevention or treatment of blood clots.

The need to wear the stockings on a one day on, one day off schedule: Wearing compression stockings on a specific schedule of one day on, one day off is not a standard recommendation. The frequency and duration of wearing compression stockings may vary based on individual needs and healthcare provider's recommendations.

The importance of wearing the stockings around the clock to ensure maximum benefit: While consistent and regular use of compression stockings is important, it is not necessary to wear them around the clock. Healthcare providers typically provide specific guidelines on how long the stockings should be worn each day, which may vary based on the severity of venous insufficiency and individual factors.

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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 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

The nurse is providing discharge teaching to a client with venous insufficiency about compression stockings. Which information is essential for the nurse in the teaching plan?

Correct Answer is D

Explanation

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