what are the nursing interventions for a patient with hypertension
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Nursing Elites

ATI LPN

ATI PN Comprehensive Predictor 2020

1. What are the nursing interventions for a patient with hypertension?

Correct answer: A

Rationale: The correct nursing interventions for a patient with hypertension involve monitoring blood pressure and educating the patient about lifestyle changes. These interventions help in managing hypertension by keeping track of the patient's blood pressure readings and empowering them with knowledge to make lifestyle modifications such as adopting a healthy diet, regular exercise, stress management, and avoiding smoking and excessive alcohol consumption. Administering antihypertensive medications (choice B) is typically done by a healthcare provider rather than a nurse. While regular monitoring of blood pressure (choice C) is important, administering diuretics is a specific medical intervention that should be prescribed by a healthcare provider. Monitoring blood glucose (choice D) is more relevant for patients with diabetes rather than hypertension.

2. What is a key nursing action for a client with a wound infection?

Correct answer: B

Rationale: Performing a wound culture before applying antibiotics is crucial for determining the specific type of infection present and selecting the most effective antibiotic treatment. Changing the dressing daily (Choice A) is a routine wound care practice but may not address the root cause of the infection. Cleansing the wound with alcohol-based solutions (Choice C) can be too harsh and delay wound healing. Applying a wet-to-dry dressing (Choice D) is an outdated practice that can cause trauma to the wound bed and hinder the healing process.

3. A nurse is caring for a client who is scheduled for surgery in the morning. The nurse learns that the client has decided not to have surgery even though they have already signed the informed consent form. Which of the following actions should the nurse take?

Correct answer: B

Rationale: The correct action for the nurse to take is to report the client's decision to the provider who obtained informed consent. This ensures that the provider is informed of the client's change in decision and can discuss the situation further with the client. Choice A is incorrect as ignoring the client's decision is not appropriate and goes against the principles of patient autonomy. Choice C is incorrect because involving the family in convincing the client can be coercive and may not respect the client's autonomy. Choice D is incorrect because the nurse should not re-sign the informed consent form without the client's consent and a discussion with the provider.

4. A nurse is collecting data from a client who has a newly applied cast to the right lower extremity. Which of the following findings should the nurse expect?

Correct answer: B

Rationale: When assessing a client with a newly applied cast, the nurse should expect a capillary refill of approximately 2 seconds, as this indicates adequate circulation. A capillary refill longer than 3 seconds suggests impaired circulation, which is abnormal. Therefore, a capillary refill of 5 seconds is the finding the nurse should expect. Pitting edema and shortness of breath are not typically directly related to a newly applied cast and should not be expected findings in this scenario.

5. A client is constipated and asks the nurse for advice. What should the nurse recommend?

Correct answer: B

Rationale: The correct recommendation for constipation is to increase dietary fiber to promote bowel movements. Dietary fiber helps add bulk to the stool, making it easier to pass and promoting regular bowel movements. Administering a laxative (Choice A) is not the first-line recommendation and should be used cautiously due to potential side effects. Resting until symptoms resolve (Choice C) and encouraging bed rest (Choice D) are not effective interventions for relieving constipation.

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