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Which of the following actions should the nurse include in the plan of care for a patient who is receiving IV nitroglycerine to treat a hypertensive emergency?
- A. Organize nursing activities so that the patient has undisturbed sleep for 6 to 8 hours at night.
- B. Assist the patient up in the chair for meals to avoid complications associated with immobility.
- C. Use an automated noninvasive blood pressure machine to obtain frequent BP measurements.
- D. Place the patient on NPO status to prevent aspiration caused by nausea and the associated vomiting.
Correct Answer: C
Rationale: Frequent monitoring of BP is needed when the patient is receiving rapid-acting IV antihypertensive medications. This can be most easily accomplished with an automated BP machine or arterial line. The patient will require frequent assessments, so allowing 6 to 8 hours of undisturbed sleep is not appropriate. When patients are receiving IV vasodilators, bed rest is maintained to prevent decreased cerebral perfusion and fainting. There is no indication that this patient is nauseated or at risk for aspiration, so an NPO status is unnecessary.
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The nurse in the emergency department received change-of-shift report on these four patients with hypertension. Which of the following patients should the nurse assess first?
- A. 52-year-old with a BP of 212/90 who has intermittent claudication
- B. 43-year-old with a BP of 190/102 who is complaining of chest pain
- C. 50-year-old with a BP of 210/110 who has a creatinine of 1.33 mcmol/L
- D. 48-year-old with a BP of 200/98 whose urine shows microalbuminuria
Correct Answer: B
Rationale: The patient with chest pain may be experiencing acute myocardial infarction and rapid assessment and intervention is needed. The symptoms of the other patients also show target organ damage, but are not indicative of acute processes.
The nurse is caring for a patient who has just diagnosed with hypertension and has a new prescription for captopril. Which of the following information is important to include when teaching the patient?
- A. Check BP daily before taking the medication.
- B. Increase fluid intake if dryness of the mouth is a problem.
- C. Include high-potassium foods such as bananas in the diet.
- D. Change position slowly to help prevent dizziness and falls.
Correct Answer: D
Rationale: The angiotensin-converting enzyme (ACE) inhibitors frequently cause orthostatic hypotension, and patients should be taught to change position slowly to allow the vascular system time to compensate for the position change. Increasing fluid intake may counteract the effect of the medication, and the patient is taught to use gum or hard candy to relieve dry mouth. The BP does not need to be checked at home by the patient before taking the medication. Because ACE inhibitors cause potassium retention, increased intake of high-potassium foods is inappropriate.
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.
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.
Which of the following assessment findings for a patient who is receiving furosemide to treat stage 2 hypertension is most important to report to the health care provider?
- A. Blood glucose level of 10 mmol/L
- B. Blood potassium level of 3.0 mmol/L
- C. Early morning BP reading of 164/96 mm Hg
- D. Orthostatic systolic BP decrease of 12 mm Hg
Correct Answer: B
Rationale: Hypokalemia is a frequent adverse effect of the loop diuretics and can cause life-threatening dysrhythmias. The health care provider should be notified of the potassium level immediately and administration of potassium supplements initiated. The elevated blood glucose and BP also indicate a need for collaborative interventions but will not require action as urgently as the hypokalemia. An orthostatic drop of 12 mm Hg is common and will require intervention only if the patient is symptomatic.