a.Evaluate effectiveness of nitroprusside therapy on blood pressure (BP).b.Assess the patient’s environment for adverse stimuli that might increase BP.c.Titrate nitroprusside to decrease mean arterial pressure (MAP) to 115 mm Hg.d.Set up the automatic noninvasive BP machine to take readings every 15 minutes.ANS: DLPN/LVN education and scope of practice include the correct use of common equipment suchas automatic noninvasive blood pressure machines. The other actions require advanced nursing judgment and education, and should be done by RNs.DIF:Cognitive Level: Apply (application)REF:696OBJ:Special Questions: DelegationTOP:Nursing Process: PlanningMSC:NCLEX: Safe and Effective Care Environment20.The charge nurse observes a new registered nurse (RN) doing discharge teaching for a patient with hypertension who has a new prescription for enalapril (Vasotec). The charge nurse will need to intervene if the new RN tells the patient toThe ACE inhibitors cause retention of potassium by the kidney, so hyperkalemia is a possible adverse effect. The other teaching by the new RN is appropriate for a patient with newly diagnosed hypertension who has just started therapy with enalapril.DIF:Cognitive Level: Apply (application)REF:691OBJ:Special Questions: DelegationTOP:Nursing Process: ImplementationMSC:NCLEX: Safe and Effective Care Environment
21.Which assessment finding for a patient who is receiving IV furosemide (Lasix) to treat stage 2hypertension is mostimportant to report to the health care provider?Hypokalemia is a frequent adverse effect of the loop diuretics and can cause life-threatening dysrhythmias. The health care provider should be notified of the potassium level immediately and administration of potassium supplements initiated. The elevated blood glucose and BP also indicate a need for collaborative interventions but will not require action as urgently as the hypokalemia. An orthostatic drop of 12 mm Hg will require intervention only if the patientis symptomatic.DIF:Cognitive Level: Analyze (analysis)REF:688OBJ:Special Questions: PrioritizationTOP:Nursing Process: EvaluationMSC:NCLEX: Physiological Integrity22.Which nursing action should the nurse take firstto assist a patient with newly diagnosed stage1 hypertension in making needed dietary changes?
- Spring '14
- Nursing, patient’s laboratory test findings