the client on a beta blocker has a blood pressure of 8858 mm hg what is the nurses priority action
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Nursing Elites

ATI RN

Cardiovascular System Exam

1. The client on a beta blocker has a blood pressure of 88/58 mm Hg. What is the nurse’s priority action?

Correct answer: A

Rationale: The correct action for the nurse to take when a client on a beta blocker presents with a blood pressure of 88/58 mm Hg is to hold the beta blocker and notify the healthcare provider. Beta blockers can further decrease blood pressure, which is already low in this case. Administering the beta blocker as ordered (Choice B) would exacerbate the hypotension. Increasing the dose of the beta blocker (Choice C) would be inappropriate and unsafe given the low blood pressure. Continuing to monitor the client and reassessing in 30 minutes (Choice D) could lead to a delay in necessary intervention. Therefore, the priority is to hold the medication and seek guidance from the healthcare provider.

2. What is an acute respiratory infection that inflames the alveoli in one or both lungs, causing them to fill with fluid or pus?

Correct answer: A

Rationale: Pneumonia is the correct answer because it is an acute respiratory infection that inflames the alveoli in one or both lungs, leading to the accumulation of fluid or pus. This condition presents with symptoms like cough, fever, and difficulty breathing. Bronchitis is the inflammation of the bronchial tubes, not the alveoli. Tuberculosis is a bacterial infection that primarily affects the lungs but does not always result in alveolar inflammation. Asthma is a chronic respiratory condition characterized by airway inflammation and narrowing, not alveolar inflammation.

3. The nurse is preparing to administer a beta blocker to a client with hypertension. What is the priority assessment?

Correct answer: B

Rationale: The correct answer is to check the client's blood pressure. Before administering a beta blocker to a client with hypertension, assessing the blood pressure is crucial because beta blockers can cause hypotension, potentially leading to adverse effects. Checking the heart rate may also be important but is secondary to monitoring the blood pressure in this scenario. Respiratory rate and temperature assessments are not directly related to assessing the client's response to a beta blocker in hypertension management, making choices C and D less relevant.

4. What is a chronic lung disease that includes chronic bronchitis and emphysema?

Correct answer: A

Rationale: The correct answer is Chronic Obstructive Pulmonary Disease (COPD). COPD is a chronic lung condition that encompasses chronic bronchitis and emphysema, causing airflow obstruction from the lungs. Pneumonia (choice B) is an infection in the lungs, while asthma (choice C) is characterized by airway inflammation and constriction. Tuberculosis (choice D) is a bacterial infection that primarily affects the lungs but is distinct from COPD.

5. When administering enoxaparin (Lovenox) to a client for DVT prophylaxis, what is the most important lab value to monitor?

Correct answer: A

Rationale: The correct answer is A: Platelet count. When administering enoxaparin (Lovenox) for DVT prophylaxis, it is crucial to monitor the platelet count as enoxaparin can lead to thrombocytopenia, a decrease in platelet levels. Monitoring the platelet count helps in early detection of this potential adverse effect. Choices B, C, and D are incorrect because PT/INR, aPTT, and hemoglobin levels are not the most important lab values to monitor specifically for enoxaparin administration and DVT prophylaxis.

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