A nurse is caring for a client who is receiving prazosin. The client's blood pressure is 100/60 mm Hg. Which of the following actions should the nurse take?
Administer a reversal agent
Initiate cardiac monitoring
Instruct the client to stand up slowly.
Inform the client to report urinary retention
The Correct Answer is C
c. Instruct the client to stand up slowly.
Explanation:
The correct answer is c. Instruct the client to stand up slowly.
Prazosin is an alpha-1 adrenergic blocker used to treat hypertension and benign prostatic hyperplasia. One of the common side effects of prazosin is orthostatic hypotension, which can cause a drop in blood pressure when changing positions from lying or sitting to standing.
In this scenario, the client's blood pressure is 100/60 mm Hg, which indicates hypotension. To prevent a sudden drop in blood pressure and related symptoms such as dizziness or fainting, the nurse should instruct the client to stand up slowly. This allows the body time to adjust to the change in position and minimizes the risk of orthostatic hypotension.
Option a, administering a reversal agent, is not necessary in this situation. Reversal agents are used to counteract the effects of specific medications when there is a need to rapidly reverse their actions. There is no indication in the scenario that the client requires a reversal agent.
Option b, initiating cardiac monitoring, is not warranted based solely on a blood pressure reading of 100/60 mm Hg. Cardiac monitoring is typically indicated when there are specific cardiac concerns or symptoms, which are not mentioned in the scenario.
Option d, informing the client to report urinary retention, is a potential side effect of prazosin but is not the most appropriate action to take in this situation. The client's blood pressure is the immediate concern, and addressing orthostatic hypotension by instructing the client to stand up slowly is the appropriate action.
By instructing the client to stand up slowly, the nurse promotes safety and minimizes the risk of orthostatic hypotension, allowing the client to adjust to the change in position and reduce the likelihood of experiencing symptoms related to low blood pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A hemoglobin (Hgb) level of 8.8 mg/dL indicates anemia, which is a decrease in the oxygen-carrying capacity of the blood. Fatigue and tiredness are common symptoms of anemia. When the body does not have enough hemoglobin to transport oxygen effectively, it can lead to feelings of fatigue and a lack of energy.
The other options are not directly associated with a low hemoglobin level:
b) "I have noticed that my fingernails are becoming thicker." Thicker fingernails are not typically associated with a low hemoglobin level. Changes in fingernails can be atributed to various factors, but they are not directly related to anemia.
c) "I have to go to the bathroom all the time." Frequent urination is not typically associated with a low hemoglobin level. It can be related to other factors such as urinary tract infections, diabetes, or diuretic use, among others.
d) "I notice that my hands are always shaky." Hand tremors are not directly associated with a low hemoglobin level. Tremors can have various causes, such as neurological conditions, medication side effects, or excessive caffeine intake, but they are not directly linked to anemia.
Correct Answer is A
Explanation
Delegating tasks involves assigning appropriate responsibilities to assistive personnel based on their level of training, competency, and scope of practice. Performing indwelling urinary catheter care is a task that can be safely delegated to an AP who has received proper training and demonstrated competency in this skill. The nurse should ensure that the AP is familiar with the facility's policies and procedures regarding catheter care and can perform the task safely and effectively.
Demonstrating how to use an incentive spirometer requires specialized knowledge and the ability to provide clear instructions. It is typically within the scope of practice of licensed healthcare professionals, such as nurses or respiratory therapists, who have the necessary expertise to properly educate and guide patients in using an incentive spirometer. This task should not be delegated to an AP.
Measuring and assessing the depth of a pressure injury requires clinical judgment and accurate evaluation, which falls within the scope of practice of a licensed nurse. It involves understanding wound assessment, proper technique for measuring depth, and interpreting the findings. This task should be performed by the nurse rather than an AP.
Changing the appliance on a new colostomy involves skills such as assessing the stoma, selecting the appropriate appliance, and ensuring proper application. This task requires specialized knowledge and training in stoma care, and it should be performed by a licensed nurse who has the expertise in managing ostomies. It should not be delegated to an AP.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today