A nurse is caring for a client who received verapamil 1 hr ago and now has a blood pressure of 80/54 mm Hg. Which of the following actions should the nurse plan to take?
Administer a bolus of IV fluids.
Administer supplemental oxygen.
Position the client's legs in a dependent position.
Administer a dose of IV diphenhydramine.
The Correct Answer is A
A. Administer a bolus of IV fluids: Verapamil, a calcium channel blocker, can cause hypotension due to vasodilation and decreased cardiac contractility. Administering IV fluids helps increase intravascular volume and improve blood pressure, supporting perfusion to vital organs.
B. Administer supplemental oxygen: While oxygen may be beneficial if hypoxia is present, the primary issue here is hypotension rather than oxygenation. Oxygen alone will not correct low blood pressure.
C. Position the client's legs in a dependent position: Elevating or positioning the legs can aid venous return temporarily, but it is not sufficient to treat significant hypotension caused by verapamil.
D. Administer a dose of IV diphenhydramine: Diphenhydramine is an antihistamine used for allergic reactions. There is no indication of an allergic reaction in this scenario, and it will not address verapamil-induced hypotension.
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Related Questions
Correct Answer is A
Explanation
A. Change the IV tubing every 24 hours: TPN solutions are rich in glucose and amino acids, creating an excellent medium for bacterial growth. Changing the IV tubing every 24 hours minimizes the risk of infection and sepsis associated with central line use.
B. Monitor the client's weight weekly: Clients receiving TPN require close monitoring of fluid status and nutritional response. Weight should be checked daily, not weekly, to promptly identify fluid imbalances or overfeeding.
C. Change the IV dressing every 96 hours: Central line dressings used for TPN should be changed every 48–72 hours (if gauze) or every 7 days (if transparent and intact), unless soiled or loose. Changing every 96 hours exceeds safe practice guidelines.
D. Perform blood glucose monitoring hourly: Hourly glucose checks are unnecessary unless the client is critically ill or experiencing unstable blood glucose levels. Typically, glucose is monitored every 4–6 hours to detect hyperglycemia related to TPN.
Correct Answer is C
Explanation
A. Decreased blood pressure: While furosemide can lower blood pressure due to fluid loss, the primary therapeutic goal in heart failure is the reduction of fluid overload and improvement in symptoms of congestion, not just lowering BP.
B. Distended neck veins: Jugular vein distention indicates fluid retention and right-sided heart failure, suggesting the medication is not achieving its intended diuretic effect.
C. Weight loss: Furosemide promotes diuresis, reducing excess fluid and relieving edema. Weight loss reflects decreased fluid retention and is a key indicator of therapeutic effectiveness in managing heart failure.
D. Increased heart rate: A rising heart rate may signal worsening heart failure or dehydration from over-diuresis, both of which indicate that the medication is not being tolerated or is not properly balanced.
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