1. A patient with a history of hypertension treated with a diuretic and an angiotensin-converting enzyme (ACE)
inhibitor arrives in the emergency department complaining of a severe headache and nausea and has a blood
pressure (BP) of 238/118 mm Hg. Which question should the nurse ask to follow up...
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QUESTIONS RNV1
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ANSWERS]
1. A patient with a history of hypertension treated with a diuretic and an angiotensin-converting enzyme (ACE)
inhibitor arrives in the emergency department complaining of a severe headache and nausea and has a blood
pressure (BP) of 238/118 mm Hg. Which question should the nurse ask to follow up on these findings?
a. “Have you recently taken any antihistamines?”
b. “Have you consistently taken your medications?”
c. “Did you take any acetaminophen (Tylenol) today?”
d. “Have there been recent stressful events in your life?”
ANS: B
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.
2. The nurse is assessing a patient who has been admitted to the intensive care unit (ICU) with a hypertensive
emergency. Which finding is most important to report to the health care provider?
a. Urine output over 8 hours is 250 mL less than the fluid intake.
b. The patient cannot move the left arm and leg when asked to do so.
c. Tremors are noted in the fingers when the patient extends the arms.
d. The patient complains of a headache with pain at level 7 of 10 (0 to 10 scale).
ANS: B
The patient’s inability to move the left arm and leg indicates that a stroke may be occurring and will require
immediate action to prevent further neurologic damage. The other clinical manifestations are also likely caused
by the hypertension and will require rapid nursing actions, but they do not require action as urgently as the
neurologic changes.
3. A patient with hypertension who has just started taking atenolol (Tenormin) returns to the health clinic after 2
weeks for a follow-up visit. The blood pressure (BP) is unchanged from the previous visit. Which action
should the nurse take first?
a. Tell the patient why a change in drug dosage is needed.
b. Ask the patient if the medication is being taken as prescribed.
c. Inform the patient that multiple drugs are often needed to treat hypertension.
d. Question the patient regarding any lifestyle changes made to help control BP.
ANS: B
Because nonadherence with antihypertensive therapy is common, the nurse’s initial action should be to
determine whether the patient is taking the atenolol as prescribed. The other actions also may be implemented,
but these would be done after assessing patient adherence with the prescribed therapy.
This study source was downloaded by 100000841417753 from CourseHero.com on 02-19-2023 02:15:33 GMT -06:00
, 4. The registered nurse (RN) is caring for a patient with a hypertensive crisis who is receiving sodium
nitroprusside . Which nursing action can the nurse delegate to an experienced licensed practical/vocational
nurse (LPN/LVN)?
a. Evaluate effectiveness of nitroprusside therapy on blood pressure (BP).
b. Assess the patient’s environment for adverse stimuli that might increase BP.
c. Titrate nitroprusside to decrease mean arterial pressure (MAP) to 115 mm Hg.
d. Set up the automatic noninvasive BP machine to take readings every 15 minutes.
ANS: D
LPN/LVN education and scope of practice include the correct use of common equipment such as automatic
noninvasive blood pressure machines. The other actions require advanced nursing judgment and education, and
should be done by RNs.
5. The charge nurse observes a new registered nurse (RN) doing discharge teaching for a patient with
hypertension who has a new prescription for enalapril (Vasotec). The charge nurse will need to intervene if the
new RN tells the patient to
a. increase the dietary intake of high-potassium foods.
b. make an appointment with the dietitian for teaching.
c. check the blood pressure (BP) at home at least once a day.
d. move slowly when moving from lying to sitting to standing.
ANS: A
The ACE inhibitors cause retention of potassium by the kidney, so hyperkalemia is a possible adverse effect.
The other teaching by the new RN is appropriate for a patient with newly diagnosed hypertension who has just
started therapy with enalapril.
6. Which assessment finding for a patient who is receiving IV furosemide (Lasix) to treat stage 2
hypertension is most important to report to the health care provider?
a. Blood glucose level of 175 mg/dL
b. Serum potassium level of 3.0 mEq/L
c. Orthostatic systolic BP decrease of 12 mm Hg
d. Most recent blood pressure (BP) reading of 168/94 mm Hg
ANS: B
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 will require
intervention only if the patient is symptomatic.
7. Which nursing action should the nurse take first to assist a patient with newly diagnosed stage 1
hypertension in making needed dietary changes?
a. Collect a detailed diet history.
b. Provide a list of low-sodium foods.
c. Help the patient make an appointment with a dietitian.
d. Teach the patient about foods that are high in potassium.
ANS: A
The initial nursing action should be assessment of the patient’s baseline dietary intake through a thorough diet
history. The other actions may be appropriate, but assessment of the patient’s baseline should occur first.
This study source was downloaded by 100000841417753 from CourseHero.com on 02-19-2023 02:15:33 GMT -06:00
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