A client who receives multiple antihypertensive medications experiences syncope due to a drop in blood pressure to 70/40 mm Hg. Which is the rationale for the nurse's decision to hold the client's scheduled antihypertensive medications?

Increased urinary clearance of the multiple medications has produced diuresis and lowered the blood pressure.

The synergistic effect of the multiple medications has resulted in drug toxicity and hypotension.

The antagonistic interaction among the various blood pressure medications has reduced their effectiveness.

The additive effect of multiple medications has caused the blood pressure to drop too low.

Answer and Explanation

The Correct Answer is D

Choice A reason: Increased urinary clearance of the multiple medications is not the cause of the client's syncope. Diuresis is a common side effect of some antihypertensive medications, such as diuretics, but it does not lower the blood pressure to a dangerous level. The nurse should monitor the client's fluid and electrolyte balance and urine output, but it is not the priority action in this situation.

Choice B reason: The synergistic effect of the multiple medications is not the cause of the client's syncope. Synergism is when two or more drugs work together to produce a greater effect than the sum of their individual effects. This can be beneficial or harmful, depending on the drugs and the doses. The nurse should check the client's medication history and avoid prescribing drugs that have a negative synergistic effect, but it is not the most likely explanation for the client's hypotension.

Choice C reason: The antagonistic interaction among the various blood pressure medications is not the cause of the client's syncope. Antagonism is when two or more drugs work against each other to reduce or cancel out their effects. This can decrease the effectiveness of the treatment and increase the risk of complications. The nurse should check the client's medication history and avoid prescribing drugs that have a negative antagonistic effect, but it is not the most likely explanation for the client's hypotension.

Choice D reason: The additive effect of multiple medications is the most likely cause of the client's syncope. Additivity is when two or more drugs have a similar effect and their combined effect is equal to the sum of their individual effects. This can lower the blood pressure too much and cause symptoms such as dizziness, fainting, and shock. The nurse should hold the client's scheduled antihypertensive medications and notify the healthcare provider. The nurse should also monitor the client's vital signs, level of consciousness, and perfusion.

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Correct Answer is D

Explanation

Choice A reason: Diabetic ketoacidosis is a complication of diabetes that occurs when the body produces high levels of ketones due to lack of insulin. Glucagon is not indicated for this condition, as it would increase the blood glucose level even more. The nurse should instruct the client and family to monitor the blood glucose and ketone levels, administer insulin as prescribed, and seek medical attention if the condition worsens.

Choice B reason: Glucagon is not used to prevent hyperglycemia, which is a high blood glucose level. Glucagon is a hormone that raises the blood glucose level by stimulating the breakdown of glycogen in the liver. The nurse should instruct the client and family to prevent hyperglycemia by following a balanced diet, taking insulin as prescribed, and exercising regularly.

Choice C reason: Glucagon is not used when the client is unable to eat during sick days, unless the client has signs of hypoglycemia, which is a low blood glucose level. Glucagon is used as a last resort when the client is unconscious or unable to swallow. The nurse should instruct the client and family to follow the sick day rules, which include monitoring the blood glucose and urine ketone levels, taking insulin as prescribed, drinking fluids, and eating small amounts of carbohydrates.

Choice D reason: Glucagon is used when the client has signs of severe hypoglycemia, such as confusion, seizures, or loss of consciousness. Glucagon is injected subcutaneously or intramuscularly by a family member or a caregiver to raise the blood glucose level quickly. The nurse should instruct the client and family to recognize the signs of hypoglycemia, treat mild to moderate hypoglycemia with oral glucose, and call 911 after administering glucagon.

A. Report the finding to the healthcare provider. B. Check the client's capillary glucose level. C. Use a pulse oximeter to assess oxygen saturation. D. Advise the client to reduce the medication dose.

Correct Answer is A

Explanation

Choice A reason: A yellow skin color may indicate jaundice, which is a sign of liver damage. Acetaminophen can cause liver toxicity, especially in high doses or with chronic use. The nurse should report this finding to the healthcare provider as soon as possible, as it may require further evaluation and treatment.

Choice B reason: Checking the client's capillary glucose level is not relevant to the finding of yellow skin color. Although diabetes can cause skin changes, such as dryness or infections, it does not cause jaundice. The nurse should focus on the potential liver problem rather than the blood sugar level.

Choice C reason: Using a pulse oximeter to assess oxygen saturation is not helpful in this situation. A low oxygen saturation may indicate hypoxia, which can affect various organs, but it does not cause jaundice. The nurse should monitor the client's respiratory status, but it is not the priority action in response to the yellow skin color.

Choice D reason: Advising the client to reduce the medication dose is not appropriate without consulting the healthcare provider. The client may need acetaminophen for pain relief, and reducing the dose may not be enough to prevent liver damage. The nurse should not make any changes to the medication regimen without the provider's order.

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A client who receives multiple antihypertensive medications experiences syncope due to a drop in blood pressure to 70/40 mm Hg. Which is the rationale for the nurse's decision to hold the client's scheduled antihypertensive medications?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A glucagon emergency kit is prescribed for a client with type 1 diabetes mellitus to be used at home. When should the nurse instruct the client and family that glucagon needs to be administered?

Correct Answer is D

Explanation

While assessing a client who takes acetaminophen for chronic pain, the nurse observes that the client's skin looks yellow in color. Which action should the nurse take in response to this finding?

Correct Answer is A

Explanation

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