A nurse is caring for a client.

Exhibits

The nurse prepares to give 2 units of insulin lispro.

What should the nurse double-check with a second nurse? Select all that apply.

A. Apply a telemetry monitor before administering the dose:

While monitoring the client's heart rate is important, applying a telemetry monitor may not be necessary at this stage. The primary concern is addressing the bradycardia and elevated blood pressure by notifying the healthcare provider.

B. Administer the dose and monitor the client's BP regularly:

Administering the dose without addressing the low heart rate and inadequate blood pressure control may not be safe. The healthcare provider should be consulted before proceeding.

The action the nurse should take when preparing to administer a scheduled dose of labetalol to a client with hypertension, with vital signs including a heart rate of 48 beats/minute and a blood pressure of 150/90 mm Hg, is:

C. Withhold the scheduled dose and notify the healthcare provider.

Explanation: Labetalol is a beta-blocker used to treat hypertension. A heart rate of 48 beats/minute indicates bradycardia, which is a potential side effect of labetalol. Additionally, the client's blood pressure remains elevated (150/90 mm Hg), which suggests that the medication may not be effectively controlling blood pressure at this time. Before administering the dose, it is important to withhold it and notify the healthcare provider to discuss the client's low heart rate and inadequate blood pressure control. The healthcare provider can assess whether a dose adjustment or alternative treatment is necessary.

D. Assess for orthostatic hypotension before administering the dose:

While orthostatic hypotension assessment is important when starting antihypertensive medications, it does not address the immediate concerns of bradycardia and elevated blood pressure. The healthcare provider should be notified before administering the medication.

A) Taking the tablet with a daily multivitamin may not be necessary and could potentially cause excess iron intake, which can be harmful.

B) Bedtime is not necessarily the best time to take the tablet; it's usually recommended to take it on an empty stomach, as mentioned above.

C) Crushing enteric-coated tablets and mixing them with pudding is not recommended. These tablets have a special coating that helps protect the stomach from irritation and crushing them may affect their effectiveness and cause gastric discomfort.

The information the nurse should include in the discharge instructions for an older adult with iron deficiency anemia taking ferrous sulfate enteric-coated tablets is:

D) Wait 2 hours after meals to take the tablet.

Explanation:

Ferrous sulfate is an iron supplement used to treat iron deficiency anemia. Taking it on an empty stomach (usually 1 to 2 hours before meals or 2 hours after meals) enhances its absorption in the small intestine. It's best absorbed in an acidic environment, so it's often recommended to take it with a small amount of vitamin C-rich food or juice (like orange juice) to improve absorption.