Chapter 34: Hypertension

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A patient with a history of hypertension treated with a diuretic and an angiotensin-converting enzyme (ACE) inhibitor arrives in the emergency department complaining of a severe headache and nausea and has a blood pressure (BP) of 238/118 mm Hg. Which question should the nurse ask to follow up on these findings?

"Have you consistently taken your medications?"

The nurse is assessing a patient who has been admitted to the intensive care unit (ICU) with a hypertensive emergency. Which finding is most important to report to the health care provider?

The patient cannot move the left arm and leg when asked to do so.

A patient with hypertension who has just started taking atenolol (Tenormin) returns to the health clinic after 2 weeks for a follow-up visit. The blood pressure (BP) is unchanged from the previous visit. Which action should the nurse take first?

Ask the patient if the medication is being taken as prescribed.

The registered nurse (RN) is caring for a patient with a hypertensive crisis who is receiving sodium nitroprusside . Which nursing action can the nurse delegate to an experienced licensed practical/vocational nurse (LPN/LVN)?

Set up the automatic noninvasive BP machine to take readings every 15 minutes.

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 to

increase the dietary intake of high-potassium foods.

Which assessment finding for a patient who is receiving IV furosemide (Lasix) to treat stage 2 hypertension is most important to report to the health care provider?

Serum potassium level of 3.0 mEq/L

Which nursing action should the nurse take first to assist a patient with newly diagnosed stage 1 hypertension in making needed dietary changes?

Collect a detailed diet history.

The nurse is caring for a 70-yr-old patient who uses hydrochlorothiazide and enalapril (Norvasc) but whose self-monitored blood pressure (BP) continues to be elevated. Which patient information may indicate a need for a change?

Patient uses ibuprofen (Motrin) treat osteoarthritis.

The nurse obtains a blood pressure of 176/82 mm Hg for a patient. What is the patient's mean arterial pressure (MAP)?

113 mm Hg

What side effects should the nurse instruct the client that are most closely associated with the use of nitroglycerin tablets? Select all that apply.

headache, flushing, hypotension, dizziness

The nurse provides discharge instructions for a client who has recovered after a cardiac catheterization. What instructions should be included? Select all that apply.

Take a shower rather than a tub bath until the puncture site heals., Drink a generous amount of fluids for the next 24 hours., Report worsening of pain in the leg that was catheterized., Change the dressing over the puncture site dailyuntil it heals

A client with CAD will undergo percutaneous transluminal coronary angioplasty (PTCA). The nurse knows that the client understands the explanation of the PTCA procedure when the client makes which statement?

A balloon-tipped catheter will be inserted into my coronary artery

While the client takes propranolol, what assessment finding can the nurse expect?

The client's pulse will be slower than in the past.

The client is told to take 81 mg of aspirin daily while waiting for the scheduled percutaneous transluminal coronary angioplasty (PTCA). What is the best nursing explanation for the drug therapy in this situation?

Aspirin tends to prevent blood clots.

When the client returns to the room after the percutaneous transluminal coronary angioplasty (PTCA) procedure, what assessment finding should be reported immediately?

Chest pain

A client is undergoing a coronary artery bypass graft (CABG) procedure. The nurse assesses the client's mental status upon being transferred from the postanesthesia recovery (PAR) room. What is the best explanation the nurse can attribute to incorrect answers to the nurse's questions?

The client is influenced by anesthesia.

Where is it best for the nurse to assess an incision when checking the client's leg following CABG surgery? In the area of the:

saphenous vein.

Which action indicates that the nurse needs to provide more instruction to a unlicensed assistive person (UAP) on how to accurately assess the client's pulse rate

The UAP places a thumb over the radial artery.

The client reports having acute pain in the incisional area. How would acute pain most likely affects the client's vital signs during the nurse's assessment?

Pulse rate will be rapid.

When the client uses a patient-controlled analgesia (PCA) infusion pump, what nursing instruction is most important to include?

"Press the control button whenever you feel you need pain medication."

What information about the client's use of a patient-controlled analgesia (PCA) pump is most important to communicate to the staff on the next shift?

The number of doses administered

What nursing assessment is a priority to determine if the client is experiencing a side effect of opioid analgesia?

Check the client's bowel elimination.

After the coronary artery bypass graft (CABG) surgery, what nursing assessment finding provides the best evidence that collateral circulation at the donor graft site is adequate?

The client's toes are warm when touched.

When the nurse applies antiembolism stockings following cardiac surgery, what measurements are necessary for ensuring an optimum fit? Select all that apply.

Measure the length from the heel to the bend of the knee., Assess the circumference of the client's calf.

The nurse prepares to ambulate a client for the first time following cardiac surgery. What item is best for the nurse to use?

Gait belt

A nurse assesses a client who had a myocardial infarction and is hypotensive. Which additional assessment finding should the nurse expect?

Heart rate of 120 beats/min

A nurse assesses a client after administering a prescribed beta blocker. Which assessment should the nurse expect to find?

Pulse decreased from 100 beats/min to 80 beats/min

A nurse assesses clients on a medical-surgical unit. Which client should the nurse identify as having the greatest risk for cardiovascular disease?

A 45-year-old American Indian woman with diabetes mellitus

A nurse assesses an older adult client who has multiple chronic diseases. The clients heart rate is 48 beats/min. Which action should the nurse take first?

Assess the clients medications.

An emergency room nurse obtains the health history of a client. Which statement by the client should alert the nurse to the occurrence of heart failure?

I get short of breath when I climb stairs.

A nurse obtains the health history of a client who is newly admitted to the medical unit. Which statement by the client should alert the nurse to the presence of edema?

My shoes fit tighter by the end of the day.

A nurse assesses an older adult client who is experiencing a myocardial infarction. Which clinical manifestation should the nurse expect?

Disorientation and confusion

A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The nurse notes that the left pedal pulse is weak. Which action should the nurse take?

Assess the color and temperature of the left leg.

A nurse assesses a client who is recovering after a left-sided cardiac catheterization. Which assessment finding requires immediate intervention?

Slurred speech and confusion

A nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment should the nurse complete prior to this procedure?

Allergies to iodine-based agents

A nurse cares for a client who is prescribed magnetic resonance imaging (MRI) of the heart. The clients health history includes a previous myocardial infarction and pacemaker implantation. Which action should the nurse take?

Notify the health care provider before scheduling the MRI.

A nurse assesses a client who is recovering from a myocardial infarction. The clients pulmonary artery pressure reading is 25/12 mm Hg. Which action should the nurse take first?

Compare the results with previous pulmonary artery pressure readings.

A nurse cares for a client who has an 80% blockage of the right coronary artery (RCA) and is scheduled for bypass surgery. Which intervention should the nurse be prepared to implement while this client waits for surgery?

Initiation of an external pacemaker

A nurse teaches a client with diabetes mellitus and a body mass index of 42 who is at high risk for coronary artery disease. Which statement related to nutrition should the nurse include in this clients teaching?

You should balance weight loss with consuming necessary nutrients.

A nurse cares for a client who has advanced cardiac disease and states, I am having trouble sleeping at night. How should the nurse respond?

Use pillows to elevate your head and chest while you are sleeping.

A nurse cares for a client who is recovering from a myocardial infarction. The client states, I will need to stop eating so much chili to keep that indigestion pain from returning. How should the nurse respond?

What do you understand about what happened to you?

A nurse prepares a client for coronary artery bypass graft surgery. The client states, I am afraid I might die. How should the nurse respond?

Tell me more about your concerns about the surgery.

An emergency department nurse triages clients who present with chest discomfort. Which client should the nurse plan to assess first?

A 58-year-old male who describes his pain as intense stabbing that spreads across his chest

A nurse auscultated heart tones on an older adult client. Which action should the nurse take based on heart tones heard?

Document the finding.

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