Page 1730 - Saunders Comprehensive Review For NCLEX-RN

B. Assessment
1. An extremely high BP; systolic over 180 mm Hg
and/or diastolic over 120 mm Hg
2. Headache
3. Drowsiness and confusion
4. Blurred vision
5. Changes in neurological status
6. Tachycardia and tachypnea
7. Dyspnea
8. Cyanosis
9. Seizures
C. Interventions
1. Maintain a patent airway.
2. Administer antihypertensive medications
intravenously as prescribed.
3. Monitor vital signs, assessing the BP every 5 minutes.
4. Monitor neurological status.
5. Maintain bed rest, with the head of the bed el-evated
at 45 degrees.
6. Assess for hypotension during the administration of
antihypertensives; place the client in a supine position
if hypotension occurs.
7. Have emergency medications and resuscitation
equipment readily available.
8. Monitor IV therapy, assessing for fluid overload.
9. Insert a Foley catheter as prescribed.
10. Monitor intake and urinary output; if oliguria or
anuria occurs, notify the PHCP.

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