ATI LPN
Lewis's Medical Surgical Nursing in Canada, 5th Edition
Chapter 35 Questions
Question 1 of 5
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?
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.
Question 2 of 5
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?
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.
Question 3 of 5
The nurse is teaching a patient with stage I hypertension about diet modifications that should be implemented. Which of the following diet choices indicates that the teaching has been effective?
Correct Answer: D
Rationale: The Dietary Approaches to Stop Hypertension (DASH) recommendations for prevention of hypertension include increasing the intake of calcium-rich foods. Caffeine restriction and decreased protein intake are not included in the recommendations. Nuts are high in beneficial nutrients and 4-5 servings weekly are recommended in the DASH diet.
Question 4 of 5
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?
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.
Question 5 of 5
Which of the following actions should the nurse in the hypertension clinic take in order to obtain an accurate baseline blood pressure (BP) for a new patient?
Correct Answer: C
Rationale: The patient should be seated to assess the initial BP and pulse. The BP is obtained in both arms, but the results of the two arms are not averaged. The patient does not need to be in the supine position. The cuff should be deflated at 2-3 mm Hg/second.