The nurse is caring for a patient with a blood pressure of 88/50 and symptomatic. The nurse recognizes which nursing action is a priority?

Prepare for the administration of IV fluids

Administer a bolus of IV fluids

Administer Atenolol stat

Administer Nitroglycerin

Answer and Explanation

The Correct Answer is B

Choice A reason: Preparing for the administration of IV fluids is important but not as immediate as administering a bolus of IV fluids. Immediate fluid resuscitation is crucial for addressing low blood pressure and improving the patient's hemodynamic status.

Choice B reason: Administering a bolus of IV fluids is the priority nursing action for a patient with symptomatic hypotension. Rapid fluid administration helps to increase blood volume and improve blood pressure, which is essential for stabilizing the patient.

Choice C reason: Administering Atenolol, a beta-blocker, is not appropriate for a patient with hypotension. Beta-blockers can further lower blood pressure and are contraindicated in this situation.

Choice D reason: Administering Nitroglycerin is not suitable for a patient with hypotension. Nitroglycerin can cause vasodilation and further decrease blood pressure, which would worsen the patient's condition.

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Correct Answer is A

Explanation

Choice A reason: This response acknowledges the client's feelings and validates their experience. It opens the door for the client to express their emotions and share their thoughts. This empathetic approach helps build trust and provides emotional support.

Choice B reason: Telling the client that it takes time to get over the loss of a loved one is a generalized statement that may not provide the support the client needs. It can come across as dismissive and may not encourage further conversation.

Choice C reason: Suggesting that the client try something to take their mind off their troubles can seem dismissive of their grief. It does not address the client's emotional needs or encourage them to talk about their feelings.

Choice D reason: While this response shows some understanding, it does not fully acknowledge the uniqueness of the client's situation. It is important to validate the client's feelings and encourage them to express their emotions.

A. "Because of the dysrhythmia, blood backs up in the legs and puts you at risk for blood clots." B. "Because the atria are quivering, blood flows sluggishly through them, and clots can form along the heart wall, which then could loosen and travel to the lungs or brain." C. "The medications that you are taking cause blood clots as a side effect so you need this medication to prevent them."

Correct Answer is B

Explanation

Choice A reason: The statement "Because of the dysrhythmia, blood backs up in the legs and puts you at risk for blood clots" is incorrect. Atrial fibrillation primarily causes blood to pool in the atria, not the legs.

Choice B reason: The statement "Because the atria are quivering, blood flows sluggishly through them, and clots can form along the heart wall, which then could loosen and travel to the lungs or brain" accurately explains the risk of clot formation in atrial fibrillation and the importance of anticoagulant therapy to prevent strokes and other complications.

Choice C reason: The statement "The medications that you are taking cause blood clots as a side effect so you need this medication to prevent them" is incorrect. Anticoagulant therapy in atrial fibrillation is used to prevent clot formation due to the arrhythmia itself, not as a counteraction to the side effects of other medications.

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The nurse is caring for a patient with a blood pressure of 88/50 and symptomatic. The nurse recognizes which nursing action is a priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The nurse is teaching a client with atrial fibrillation about the need to begin long-term anticoagulant therapy. Which explanation should the nurse use to best describe the reasoning for this therapy?

Correct Answer is B

Explanation

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