Upgrade to remove ads
Only $35.99/year

NCLEX STYLE QUESTIONS EXAM 4

Terms in this set (58)

Which action will the nurse in the hypertension clinic take in order to obtain an accurate baseline blood pressure (BP) for a new patient?
a. Obtain a BP reading in each arm and average the results.
b. Deflate the BP cuff at a rate of 5 to 10 mm Hg per second.
c. Have the patient sit in a chair with the feet flat on the floor.
d. Assist the patient to the supine position for BP measurements.
ANS: C
The patient should be seated with the feet flat on the floor. 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 to 3 mm Hg per second.
The nurse obtains this information from a patient with prehypertension. Which finding is most important to address with the patient?
a. Low dietary fiber intake
b. No regular aerobic exercise
c. Weight 5 pounds above ideal weight
d. Drinks wine with dinner once a week
ANS: B
The recommendations for preventing hypertension include exercising aerobically for 30 minutes most days of the week. A weight that is 5 pounds over the ideal body weight is not a risk factor for hypertension. The Dietary Approaches to Stop Hypertension (DASH) diet is high in fiber, but increasing fiber alone will not prevent hypertension from developing. The patient's alcohol intake will not increase the hypertension risk.
After giving a patient the initial dose of oral labetalol (Normodyne) for treatment of hypertension, which action should the nurse take?
a. Encourage oral fluids to prevent dry mouth or dehydration.
b. Instruct the patient to ask for help if heart palpitations occur.
c. Ask the patient to request assistance when getting out of bed.
d. Teach the patient that headaches may occur with this medication.
ANS: C
Labetalol decreases sympathetic nervous system activity by blocking both α- and β-adrenergic receptors, leading to vasodilation and a decrease in heart rate, which can cause severe orthostatic hypotension. Heart palpitations, dehydration, and headaches are possible side effects of other antihypertensives.
After the nurse teaches the patient with stage 1 hypertension about diet modifications that should be implemented, which diet choice indicates that the teaching has been effective?
a. The patient avoids eating nuts or nut butters.
b. The patient restricts intake of dietary protein.
c. The patient has only one cup of coffee in the morning.
d. The patient has a glass of low-fat milk with each meal.
ANS: D
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 to 5 servings weekly are recommended in the DASH diet.
A patient has just been diagnosed with hypertension and has a new prescription for captopril (Capoten). Which 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.
ANS: D
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.
A patient is diagnosed with hypertension and nadolol (Corgard) is prescribed. The nurse should consult with the health care provider before giving this medication upon finding a history of
a. asthma.
b. peptic ulcer disease.
c. alcohol dependency.
d. myocardial infarction (MI).
ANS: A
Nonselective β-blockers block β1- and β2-adrenergic receptors and can cause bronchospasm, especially in patients with a history of asthma. β-blockers will have no effect on the patient's peptic ulcer disease or alcohol dependency. β-blocker therapy is recommended after MI.
A 52-year-old patient who has no previous history of hypertension or other health problems suddenly develops a BP of 188/106 mm Hg. After reconfirming the BP, it is appropriate for the nurse to tell the patient that
a. a BP recheck should be scheduled in a few weeks.
b. the dietary sodium and fat content should be decreased.
c. there is an immediate danger of a stroke and hospitalization will be required.
d. more diagnostic testing may be needed to determine the cause of the hypertension.
ANS: D
A sudden increase in BP in a patient over age 50 with no previous hypertension history or risk factors indicates that the hypertension may be secondary to some other problem. The BP will need rapid treatment and ongoing monitoring. If the patient has no other risk factors, a stroke in the immediate future is unlikely. There is no indication that dietary salt or fat intake have contributed to this sudden increase in BP, and reducing intake of salt and fat alone will not be adequate to reduce this BP to an acceptable level.
Which action will be included in the plan of care when the nurse is caring for a patient who is receiving sodium nitroprusside (Nipride) 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.
ANS: C
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.
The nurse has just finished teaching a hypertensive patient about the newly prescribed quinapril (Accupril). Which patient statement indicates that more teaching is needed?
a. "The medication may not work as well if I take any aspirin."
b. "The doctor may order a blood potassium level occasionally."
c. "I will call the doctor if I notice that I have a frequent cough."
d. "I won't worry if I have a little swelling around my lips and face."
ANS: D
Angioedema occurring with angiotensin-converting enzyme (ACE) inhibitor therapy is an indication that the ACE inhibitor should be discontinued. The patient should be taught that if any swelling of the face or oral mucosa occurs, the health care provider should be immediately notified because this could be life threatening. The other patient statements indicate that the patient has an accurate understanding of ACE inhibitor therapy.
During change-of-shift report, the nurse obtains this information about a hypertensive patient who received the first dose of propranolol (Inderal) during the previous shift. Which information indicates that the patient needs immediate intervention?
a. The patient's most recent BP reading is 156/94 mm Hg.
b. The patient's pulse has dropped from 64 to 58 beats/minute.
c. The patient has developed wheezes throughout the lung fields.
d. The patient complains that the fingers and toes feel quite cold.
ANS: C
The most urgent concern for this patient is the wheezes, which indicate that bronchospasm (a common adverse effect of the noncardioselective β-blockers) is occurring. The nurse should immediately obtain an oxygen saturation measurement, apply supplemental oxygen, and notify the health care provider. The mild decrease in heart rate and complaint of cold fingers and toes are associated with β-receptor blockade but do not require any change in therapy. The BP reading may indicate that a change in medication type or dose may be indicated; however, this is not as urgently needed as addressing the bronchospasm.
A patient has been diagnosed with possible white coat hypertension. Which action will the nurse plan to take next?
a. Schedule the patient for frequent BP checks in the clinic.
b. Instruct the patient about the need to decrease stress levels.
c. Tell the patient how to self-monitor and record BPs at home.
d. Teach the patient about ambulatory blood pressure monitoring.
ANS: C
Having the patient self-monitor BPs at home will provide a reliable indication about whether the patient has hypertension. Frequent BP checks in the clinic are likely to be high in a patient with white coat hypertension. Ambulatory blood pressure monitoring may be used if the data from self-monitoring is unclear. Although elevated stress levels may contribute to hypertension, instructing the patient about this is unlikely to reduce BP.
Which BP finding by the nurse indicates that no changes in therapy are needed for a patient with stage 1 hypertension who has a history of heart failure?
a. 108/64 mm Hg
b. 128/76 mm Hg
c. 140/90 mm Hg
d. 136/ 82 mm Hg
ANS: B
The goal for antihypertensive therapy for a patient with hypertension and heart failure is a BP of <130/80 mm Hg. The BP of 108/64 may indicate overtreatment of the hypertension and an increased risk for adverse drug effects. The other two blood pressures indicate a need for modifications in the patient's treatment.
Which information should the nurse include when teaching a patient with newly diagnosed hypertension?
a. Dietary sodium restriction will control BP for most patients.
b. Most patients are able to control BP through lifestyle changes.
c. Hypertension is usually asymptomatic until significant organ damage occurs.
d. Annual BP checks are needed to monitor treatment effectiveness.
ANS: C
Hypertension is usually asymptomatic until target organ damage has occurred. Lifestyle changes and sodium restriction are used to help manage blood pressure, but drugs are needed for most patients. BP should be checked by the health care provider every 3 to 6 months.
The nurse in the emergency department received change-of-shift report on four patients with hypertension. Which patient 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 1.5 mg/dL
d. 48-year-old with a BP of 200/98 whose urine shows microalbuminuria
ANS: B
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 reviewing the laboratory tests for a patient who has recently been diagnosed with hypertension. Which result is most important to communicate to the health care provider?
a. Serum creatinine of 2.6 mg/dL
b. Serum potassium of 3.8 mEq/L
c. Serum hemoglobin of 14.7 g/dL
d. Blood glucose level of 98 mg/dL
ANS: A
The elevated creatinine indicates renal damage caused by the hypertension. The other laboratory results are normal.
Sets with similar terms