Nokea
The nurse is caring for a patient who is experiencing a hypertensive crisis and is receiving IV labetalol. Which of the following time frequencies should the nurse assess the patients' blood pressure and pulse during the initial administration of this medication?
- A. 2-3 minutes
- B. 5-10 minutes
- C. 15-30 minutes
- D. Hourly
Correct Answer: A
Rationale: Administered intravenously, the drugs have a rapid (within seconds to minutes) onset of action. The patient's BP and pulse should be taken every 2-3 minutes during the initial administration of these drugs.
You may also like to solve these questions
The nurse is providing nutritional teaching to a patient with hypertension. Which of the following food groups should the nurse tell the patient that they should have four to five daily servings of?
- A. Whole grains
- B. Vegetables
- C. Meat, fish, and poultry
- D. Fat-free dairy food
- E. Fruit
Correct Answer: B,E
Rationale: Patients should be taught to have four to five daily servings of fruits and vegetables. Whole grains should be seven to eight servings per day. Meat, fish, and poultry are limited to less than 170 g/day. Low-fat dairy foods should be two to three servings per day.
The nurse is caring for a 52-year-old patient who has no previous history of hypertension or other health problems and has suddenly developed a BP of 188/106 mm Hg. After reconfirming the BP, which of the following information is best for the nurse to tell the patient?
- A. A BP recheck should be scheduled in a few weeks.
- B. The dietary sodium and fat content should be decreased.
- C. There is an immediate danger of a stroke and hospitalization will be required.
- D. More diagnostic testing may be needed to determine the cause of the hypertension.
Correct Answer: D
Rationale: A sudden increase in BP in a patient over age 50 or under age 20 with no previous hypertension history or risk factors indicates that the hypertension may be secondary to some other problem. The BP will need rapid treatment and ongoing monitoring. If the patient has no other risk factors, a stroke in the immediate future is unlikely. There is no indication that dietary salt or fat intake has contributed to this sudden increase in BP, and reducing intake of salt and fat alone will not be adequate to reduce this BP to an acceptable level.
The nurse is caring for a patient with hypertension and has just administered the initial dose of labetalol. Which of the following actions should the nurse take?
- A. Encourage oral fluids to prevent dry mouth or dehydration.
- B. Instruct the patient to ask for help if heart palpitations occur.
- C. Ask the patient to request assistance when getting out of bed.
- D. Teach the patient that headaches may occur with this medication.
Correct Answer: C
Rationale: Labetalol decreases sympathetic nervous system activity by blocking both ?±- and β-adrenergic receptors, leading to vasodilation and a decrease in heart rate, which can cause severe orthostatic hypotension. Heart palpitations, dehydration, and headaches are possible adverse effects of other antihypertensives.
During change-of-shift report, the nurse obtains this information about a patient who is hypertensive and received the first dose of propranolol during the previous shift. Which of the following information indicates that the patient needs immediate intervention?
- A. The patient's most recent BP reading is 156/94 mm Hg.
- B. The patient's pulse has dropped from 64 to 58 beats/minute.
- C. The patient has developed wheezes throughout the lung fields.
- D. The patient complains that the fingers and toes feel quite cold.
Correct Answer: C
Rationale: The most urgent concern for this patient is the wheezes, which indicate that bronchospasm (a common adverse effect of the noncardioselective β-adrenergic blockers) is occurring. The nurse should immediately obtain an oxygen saturation measurement, apply supplemental oxygen, and notify the health care provider. The mild decrease in heart rate and complaint of cold fingers and toes do not require any change in therapy. The BP reading may indicate that a change in medication type or dose may be indicated; however, this is not as urgently needed as addressing the bronchospasm.
The nurse is admitting a patient with a history of hypertension and is being treated with a diuretic and an angiotensin-converting enzyme (ACE) inhibitor to the emergency department. The patient has symptoms of a severe headache and has a BP of 240/118 mm Hg. Which of the following questions should the nurse ask first?
- A. Did you take any acetaminophen today?
- B. Do you have any recent stressful events in your life?
- C. Have you been consistently taking your medications?
- D. Have you recently taken any antihistamine medications?
Correct Answer: C
Rationale: Sudden withdrawal of antihypertensive medications can cause rebound hypertension and hypertensive crisis. Although many over-the-counter medications can cause hypertension, antihistamines and acetaminophen do not increase BP. Stressful events will increase BP but not usually to the level seen in this patient.