What is the primary action when a client is experiencing a hypertensive emergency?

Correct Answer: A

Rationale: The correct answer is A: Administer antihypertensive medication. In a hypertensive emergency, the priority is to lower blood pressure quickly to prevent organ damage. Antihypertensive medications like nitroprusside or labetalol are used for this purpose. Placing the client in a comfortable position and administering oxygen (B) may be beneficial, but lowering the blood pressure is the primary action. Monitoring blood pressure and administering antihypertensive medication (C) is correct, but the emphasis should be on immediate intervention. Monitoring the client's ECG (D) is important but not the primary action in a hypertensive emergency.

Correct Answer: D

Rationale: I must correct you on this question. The correct answer for the most appropriate action for a nurse to take when a client develops a deep vein thrombosis (DVT) is not D. The correct answer should be C: Provide anticoagulant therapy. Anticoagulant therapy is the standard treatment for DVT to prevent the blood clot from getting larger and to reduce the risk of it breaking loose and causing a pulmonary embolism. Elevating the leg and applying compression can help with symptoms but are not the primary treatment for DVT. Massage is contraindicated as it can dislodge the blood clot.

Correct Answer: C

Rationale: The correct answer is C: Monitor the client's blood pressure. When a client develops a fever after surgery, it could indicate various causes, including infection or inflammatory response. Monitoring blood pressure is essential to assess circulatory status, as fever can lead to increased heart rate and decreased blood pressure. Administering antibiotics (choice A) should only be done if infection is confirmed. Monitoring temperature and assessing for infection (choice B) is important but not the immediate priority. Administering fluid resuscitation (choice D) may be necessary based on the client's overall condition but should be guided by monitoring blood pressure.

Correct Answer: A

Rationale: The correct answer is A: Administer antiemetics. This intervention helps to reduce nausea and vomiting by blocking the neurotransmitters responsible for triggering these symptoms. Administering antiemetics is the most direct and effective approach to address severe nausea and vomiting post-surgery. Choice B (Placing the client in a supine position) is incorrect because it does not directly address the underlying cause of nausea and vomiting. Choice C (Providing hydration) is important but may not alleviate the symptoms of severe nausea and vomiting. Choice D (Monitoring bowel sounds) is important for assessing gastrointestinal motility but does not directly address the immediate symptoms of nausea and vomiting.

Correct Answer: A

Rationale: The correct answer is A: Administer aspirin. Aspirin helps prevent further clot formation by inhibiting platelet aggregation, reducing the risk of additional heart damage. It is a standard treatment in acute myocardial infarction. Administering morphine (B) may be considered for pain relief but is not the primary intervention. Monitoring vital signs (C) is important, but not the primary intervention. Administering fibrinolytics (D) is indicated in certain cases but is not the primary intervention and requires specific criteria and caution.