Which action will be included in the plan of care when the nurse is caring for a patient who is receiving nicardipine (Cardene) to treat a hypertensive emergency?
a. Keep the patient NPO to prevent aspiration caused by nausea and possible vomiting.
b. Organize nursing activities so that the patient has undisturbed sleep for 6 to 8 hours at night.
c. Assist the patient up in the chair for meals to avoid complications associated with immobility.
d. Use an automated noninvasive blood pressure machine to obtain frequent blood pressure (BP) measurements.
ANS: D
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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