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The nurse is providing care to a client being treated for a hypertensive emergency. Which of the following would be appropriate for the nurse to do?
- A. Take a blood pressure every 30 minutes.
- B. Alternate the arms for assessing the blood pressure and pulse.
- C. Continuously monitor the client's status.
- D. Measure the pulse rate every hour.
Correct Answer: C
Rationale: When the patient has severe hypertension, does not have the expected response to drug therapy, or is critically ill, continuous monitoring is performed. The blood pressure should be taken in the same arm and same position each time.
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A client who is prescribed losartan for hypertension has stopped taking the drug immediately after experiencing adverse reactions. The nurse would be alert for which of the following due to abrupt discontinuation?
- A. Breathing difficulty
- B. Rebound hypertension
- C. Orthostatic hypotension
- D. Anginal attacks
Correct Answer: B
Rationale: Rebound hypertension will occur in clients when antihypertensives are abruptly discontinued. In rebound hypertension, there is a sudden rise in blood pressure when the antihypertensives are withheld. Orthostatic hypotension, anginal attacks, and breathing difficulty are the adverse reactions associated with antihypertensive drug usage and may not occur on stopping the drug.
When providing care to a client with hypertension who is receiving antihypertensive therapy, which assessment would be the highest priority?
- A. Pain rating
- B. Blood pressure monitoring
- C. Weight measurement
- D. Complaints of adverse reactions
Correct Answer: B
Rationale: Although assessing for pain, measuring weight, and assessing for complaints of adverse reactions are important, monitoring the client's blood pressure would have the highest priority because the drug therapy regimen may need to be adjusted or changed if the client's response is inadequate.
A client is prescribed an antihypertensive drug. Which of the following would the nurse include in the teaching plan to promote the best outcome for the client? Select all that apply.
- A. Never discontinue use of the antihypertensive drug except on the advice of the physician.
- B. Avoid the use of nonprescription drugs unless approved by the physician.
- C. Avoid alcohol unless its use has been approved by the physician
- D. Know that unexplained weakness or fatigue is a normal adverse reaction.
- E. Notify the physician if the diastolic pressure suddenly increases to 130 \mathrm{~mm} \mathrm{Hg} or higher.
Correct Answer: A,B,C,E
Rationale: The client should be told to never discontinue the drug unless advised to do so, avoid nonprescription drugs unless approved, avoid alcohol unless it's approved, and notify the physician if the diastolic pressure suddenly increases to 130 \mathrm{~mm} \mathrm{Hg} or higher. The client also should contact the physician if unexplained weakness or fatigue occurs.
After teaching a group of nursing students about antihypertensive drugs, the instructor determines a need for additional teaching when the students identify which of the following as an angiotensin-converting enzyme inhibitor?
- A. Pindolol
- B. Benazepril
- C. Quinapril
- D. Enalapril
Correct Answer: A
Rationale: Pindolol is a beta-adrenergic blocker. Benazepril, quinapril, and enalapril are ACEIs.
While reviewing a client's lab work, the nurse notices the client's potassium is elevated. The nurse checks the client's medication record. Which of the following, if found, would the nurse identify as contributing to the client's elevated potassium level? Select all that apply.
- A. Atenolol
- B. Aliskiren
- C. Clonidine
- D. Metoprolol
- E. Eplerenone
Correct Answer: B,E
Rationale: Direct renin inhibitors such as aliskiren and the drug eplerenone can cause hyperkalemia. Atenolol and metoprolol are beta blockers. Clonidine is a centrally acting adrenergic drug.