A female client who is admitted to the mental health unit for opiate dependency is receiving clonidine 0.1 mg by mouth (PO) for withdrawal symptoms.
The client begins to complain of feeling nervous and tells the nurse that her bones are itching.
Which finding should the nurse identify as a contraindication for administering the medication?
Hypertension.
Apical heart rate 72 beats/minute.
Muscle weakness.
Blood pressure 90/76 mm Hg.
The Correct Answer is D
The correct answer is Choice D.
Choice A rationale:
Hypertension is not a contraindication for administering clonidine. In fact, clonidine is often used to treat hypertension. It works by decreasing the levels of certain chemicals in your blood, allowing your blood vessels to relax and your heart to beat more slowly and easily.
Choice B rationale:
An apical heart rate of 72 beats/minute is within the normal range (60-100 beats/minute) and would not be a contraindication for administering clonidine. Clonidine can lower heart rate, so it’s important to monitor heart rate, but a normal heart rate does not preclude its use.
Choice C rationale:
Muscle weakness is not a specific contraindication for the use of clonidine. While muscle weakness can be a side effect of many medications, it is not typically associated with clonidine. However, if a patient was experiencing severe or unusual muscle weakness, it would be important for the healthcare provider to evaluate this symptom.
Choice D rationale:
A blood pressure of 90/76 mm Hg could be a contraindication for the use of clonidine. Clonidine is a medication that is used to lower blood pressure, and if a patient’s blood pressure is already low, further lowering it could lead to symptoms such as dizziness, fainting, or even shock. Therefore, it would be important to monitor the patient’s blood pressure closely while they are taking this medication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
The correct answers are B, C, and E: Gently close the eyes, Place a small pillow under the head, and Remove resuscitation equipment from the room.
Choice B rationale: Gently closing the eyes demonstrates respect for the deceased and can provide a more peaceful appearance for the family.
Choice C rationale: Placing a small pillow under the head is a way to provide comfort and dignity in death, as well as to create a more natural appearance.
Choice E rationale: Removing resuscitation equipment from the room allows for a more serene environment for the family to grieve and say their final goodbyes.
Choice A rationale: Dentures should be left in place, as they contribute to a more natural appearance of the deceased. The exception is if the family requests their removal or if it is the facility's policy to remove dentures.
Choice D rationale: Applying a body shroud is unnecessary when the family has requested to view the body before it is taken to the funeral home. Shrouds are typically used during transportation or if the family does not wish to view the body.
Correct Answer is C
Explanation
Medication administration is a process that involves prescribing, dispensing, and giving medications to patients. It is a critical and complex task that requires accuracy, safety, and adherence to the rights of medication administration, such as the right patient, right drug, right dose, right route, right time, right documentation, and right response.
When a male client tells the practical nurse (PN) that the pill he has been taking at home is a different color and size than the one the PN is trying to give him now, this may indicate a potential medication error or discrepancy. A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm. A medication discrepancy is any difference between the current and previous medication regimens of a patient.
The PN should respond to the client's concern by telling him that the PN will verify that the dispensed medication is the valid prescription. This means that the PN will check the medication label, the medication order, and the medication administration record (MAR) to confirm that the medication given to the client matches the one prescribed by the healthcare provider. The PN will also compare the dispensed medication with a drug reference guide or a picture of the medication to ensure that it is the correct drug and dosage form. The PN will also report any suspected errors or discrepancies to the healthcare provider or the pharmacy for clarification or correction.
Options A, B, and D are incorrect answers, as they do not reflect the appropriate or responsible actions for the PN to take when faced with a possible medication error or discrepancy.
Option A is incorrect because explaining that the healthcare provider probably prescribed a different medication while he is hospitalized is not true or helpful, as it does not verify or resolve the issue.
Option B is incorrect because telling the client that he is probably confused since being hospitalized tends to disorient clients is rude and dismissive, as it does not acknowledge or address the client's concern.
Option D is incorrect because explaining that the pharmacy often substitutes generic equivalents for more expensive brands is not accurate or relevant, as it does not verify or resolve the issue.
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