The nurse must administer 1600 mL of total parenteral nutrition (TPN) over 24 hours. The nurse should set the IV pump to deliver how many mL/hr? (Round to the nearest tenth, do not use trailing zeros, use a leading zero if it applies)

Notify the surgeon of the blood pressure: While notifying the surgeon of the elevated blood pressure is important, it is not the immediate first action. The nurse should first address the elevated blood pressure by administering the prescribed antihypertensive medication. Once the medication is given, the nurse can then notify the surgeon if the blood pressure remains elevated or if there are any other concerns.

Choice B reason:

Document the blood pressure on the pre-op checklist: Documentation is crucial for maintaining accurate medical records, but it is not the first action in this scenario. The nurse should prioritize administering the antihypertensive medication to manage the client’s elevated blood pressure. After addressing the immediate concern, the nurse can document the blood pressure and any interventions taken.

Choice C reason:

Have the client relax and take deep breaths: Encouraging the client to relax and take deep breaths can help lower blood pressure temporarily, but it is not a substitute for administering the prescribed antihypertensive medication. This action can be taken in conjunction with medication administration but should not be the first or only action.

Choice D reason:

Administer the antihypertensive medication: Administering the antihypertensive medication is the correct first action. The client’s blood pressure is significantly elevated at 174/88, and the medication is necessary to manage this condition. According to perioperative guidelines, most antihypertensive medications should be continued until surgery to prevent complications such as hypertensive crises. Administering the medication will help stabilize the client’s blood pressure and reduce the risk of perioperative complications.

Choice A reason:

A sputum culture of Mycobacterium tuberculosis is the definitive test for diagnosing tuberculosis (TB). This test involves collecting a sputum sample and culturing it to detect the presence of Mycobacterium tuberculosis, the bacteria that cause TB. It is considered the gold standard for confirming active TB infection.

Choice B reason:

The Tuberculin (PPD) skin test, also known as the Mantoux test, is used to screen for TB infection. It can indicate whether a person has been exposed to TB bacteria, but it cannot confirm active TB disease. A positive result requires further testing, such as a sputum culture, to confirm the diagnosis.

Choice C reason:

An acid-fast bacillus (AFB) smear is a quick test that can detect the presence of mycobacteria in a sputum sample. While it can provide a preliminary indication of TB, it is not definitive. A positive AFB smear must be followed by a sputum culture to confirm the diagnosis.

Choice D reason:

A chest X-ray can show abnormalities in the lungs that are suggestive of TB, such as cavities or infiltrates. However, it cannot confirm the diagnosis on its own. Chest X-rays are used in conjunction with other tests, such as sputum culture and AFB smear, to diagnose TB.