A nurse is administering nicardipine to a client who has a BP of 180/120 mm Hg. Which of the following actions should the nurse take first?
A. Monitor the client's BP every 5 minutes.
B. Assist the client to make lifestyle changes.
C. Instruct the client to restrict sodium intake.
D. Check for orthostatic hypertension.
Answer (2)
In response to a client's high blood pressure of 180/120 mm Hg while administering nicardipine, the nurse should first monitor the client's blood pressure every 5 minutes. This allows the nurse to assess the effectiveness of the medication and ensure patient safety. Thus, the best option is A. Monitor the client's BP every 5 minutes.
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When a nurse is administering nicardipine to a client with a high blood pressure reading of 180/120 mm Hg, the nurse's first priority should be to manage the client's acute hypertension effectively and safely.
In this scenario, the most immediate concern is the heightened blood pressure, which poses a risk to the client's health. Therefore, monitoring how the client responds to the medication is crucial.
A. Monitor the client's BP every 5 minutes.
This action is the most appropriate and immediate response because:
Why: Nicardipine is a fast-acting medication often used in settings like hospitals to quickly lower blood pressure. It's important to monitor the client's blood pressure closely to ensure it is decreasing effectively and safely.
How: By monitoring the blood pressure at frequent intervals (every 5 minutes), the nurse can promptly notice changes or any adverse reactions to the medication.
What: Monitoring vital signs continually also helps to assess the effectiveness of the treatment and guide any necessary adjustments or interventions.
Options B, C, and D, while important in the long-term management of hypertension, do not address the immediate critical need to safely reduce the client’s dangerously high blood pressure.
Therefore, in this situation, option A is the correct action for the nurse to take first.
