A client comes to the emergency department with a blood pressure of 200/120 mmHg. The health care provider orders hydralazine (Apresoline) IV. What will the nurse's priority assessment include?
1. Hypotension and bradycardia
2. Hypotension and tachypnea
3. Hypotension and hyperthermia
4. Hypotension and tachycardia
Correct Answer: 4
Rationale 1: Direct vasodilators produce hypotension and tachycardia, not bradycardia.
Rationale 2: Direct vasodilators do not affect respiratory rate.
Rationale 3: Direct vasodilators do not affect body temperature.
Rationale 4: Direct vasodilators produce reflex tachycardia, a compensatory response to the sudden decrease in blood pressure caused by the drug.
Global Rationale: Direct vasodilators produce reflex tachycardia, a compensatory response to the sudden decrease in blood pressure caused by the drug. Direct vasodilators produce hypotension and tachycardia, not bradycardia. Direct vasodilators do not affect respiratory rate or body temperature.
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The nurse is assessing the body weight as a percentage of ideal body weight on an adolescent patient who was admitted for suspected anorexia nervosa. The patient's usual weight was 125 pounds, but today she weighs 98 pounds
The nurse calculates the patient's ideal body weight and concludes that the patient is: a. Experiencing mild malnutrition. b. Experiencing moderate malnutrition. c. Experiencing severe malnutrition. d. Still within expected parameters with her current weight.
A client is to be transferred from bed to stretcher, and maximum assistance is required. Which of these steps is essential when two nurses are performing this transfer?
a. Place a lift sheet under the client's back, trunk, and upper legs after logrolling the client to one side. b. Have both nurses on the same side of the bed at all times. c. Place pillows on the stretcher before the client is transferred. d. Clamp any drainage tubes to prevent spills.
Which historical event caused dramatic changes in home care nursing?
a. Passage of Medicare legislation b. Establishment of Visiting Nurse Associations c. Creation of the Montefiore Hospital Home Care Program d. Provision of funds by the Civil Works Administration
A nurse at a long-term care facility is caring for an elderly client with multiple sclerosis. What measures should the nurse take when storing medications for this client?
A) Label the medication with the client's medical record number. B) Provide details about the medication name and its dosage on its label. C) Relabel the medication if the content on the label is illegible. D) Record the manufacturing date of the medication on the label.