a client with a completed ischemic stroke has a blood pressure of 18090 mm hg which action should the nurse implement
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Nursing Elites

HESI RN

HESI Medical Surgical Practice Exam Quizlet

1. A client with a completed ischemic stroke has a blood pressure of 180/90 mm Hg. Which action should the nurse implement?

Correct answer: D

Rationale: In a client with a completed ischemic stroke, an elevated blood pressure like 180/90 mm Hg requires immediate intervention to prevent further damage. Giving an antihypertensive medication is essential to reduce the risk of recurrent stroke or complications related to hypertension. Positioning the head of the bed flat, withholding IV fluids, or administering a bolus of IV fluids are not appropriate actions for managing elevated blood pressure in this scenario and may not address the underlying cause of the hypertension or prevent potential complications.

2. A client scheduled for the surgical creation of an ileal conduit expresses anxiety and asks about having a drainage tube. How should the nurse respond?

Correct answer: D

Rationale: The most appropriate response for the nurse is to offer the client the opportunity to speak with someone who has undergone the same procedure. This allows the client to gain insight, ask questions, and share concerns with someone who has firsthand experience, which can help alleviate anxiety and promote a positive self-image. Seeking an antianxiety medication does not address the client's emotional concerns or promote a positive attitude towards the procedure. Discussing the procedure with the doctor again may provide more information but may not offer the same level of emotional support and understanding as speaking with someone who has lived through the experience. Commenting on the convenience of not having to search for a bathroom minimizes the client's anxiety and overlooks the emotional aspect of the client's concerns.

3. The healthcare provider is assessing a client with chronic renal failure who is receiving peritoneal dialysis. Which of the following findings would indicate a complication of the treatment?

Correct answer: B

Rationale: Cloudy dialysate outflow is a sign of peritonitis, a serious complication of peritoneal dialysis that requires immediate medical attention. Peritonitis, an infection of the peritoneum, the lining of the abdominal cavity, can lead to severe complications if not treated promptly. Clear dialysate outflow is an expected finding in peritoneal dialysis, indicating proper functioning of the process. Decreased urine output is common in clients with renal failure due to impaired kidney function. Increased blood pressure may be present in renal failure but is not a direct complication of peritoneal dialysis.

4. A 57-year-old male client is scheduled to have a stress-thallium test the following morning and is NPO after midnight. At 0130, he is agitated because he cannot eat and is demanding food. Which response is best for the nurse to provide to this client?

Correct answer: D

Rationale: Being direct and explaining to the client that the test requires him to be NPO, is the most therapeutic statement because the nurse is responding to the client's question and providing him the reason why.

5. The healthcare provider notes a blood pressure of 160/90 mm Hg in a patient taking a thiazide diuretic. The patient reports taking an herbal medication that a friend recommended. Which herbal product is likely, given this patient’s blood pressure?

Correct answer: A

Rationale: The correct answer is A: Ginkgo. Increased blood pressure can result when ginkgo is used in combination with a thiazide diuretic. Option B (Hawthorn) is incorrect because hawthorn is more commonly associated with lowering blood pressure. Option C (Licorice) is incorrect because licorice can lead to sodium and water retention, potentially exacerbating hypertension. Option D (St. John’s wort) is incorrect as it is not typically associated with significant blood pressure effects.

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