A nurse is collecting data from a client following his first dose of captopril.
The client's blood pressure is 88/60 mm Hg. Which of the following actions should the nurse take first?
Check blood pressure with the client standing.
Administer a 0.9% sodium chloride IV bolus.
Place the client in a supine position.
Measure blood pressure with the client sitting.
The Correct Answer is C
Choice A rationale:
Checking blood pressure with the client standing could exacerbate the client’s symptoms due to orthostatic hypotension, which is a common side effect of captopril.
Choice B rationale:
Administering a 0.9% sodium chloride IV bolus could be considered if the client’s blood pressure does not improve with positioning changes or if the client’s condition worsens.
Choice C rationale:
Placing the client in a supine position can help increase blood flow to the brain and alleviate symptoms of low blood pressure. This should be the first action taken by the nurse.
Choice D rationale:
Measuring blood pressure with the client sitting could also exacerbate symptoms due to orthostatic hypotension. It would be more appropriate after the client’s condition has stabilized.
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Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Pinching the tube while connecting the syringe to it could potentially damage the tube and does not aid in medication administration.
Choice B rationale:
Elevating the head of the client’s bed to only 10° may increase the risk of aspiration. The head of the bed should be elevated to at least 30° during medication administration and for at least an hour afterward.
Choice C rationale:
Flushing the tube with normal saline following medication administration helps ensure that all medication has been administered and helps maintain tube patency.
Choice D rationale:
Combining crushed medications together in a single syringe can lead to drug interactions and can also increase the risk of tube clogging. Each medication should be administered separately.
Correct Answer is ["1"]
Explanation
To solve this problem, we first need to convert the client’s weight from pounds to kilograms. Then, we can calculate the total amount of amikacin needed. Finally, we can find out how many milliliters of amikacin injection the nurse should administer.
- Convert the client’s weight to kilograms: Given that 1 kg = 2.2 lbs, we can calculate the client’s weight in kilograms as follows:
Weightinkg=WeightinlbsConversionfactor=110lbs2.2lbs/kg≈50kgWeightinkg=ConversionfactorWeightinlbs=2.2lbs/kg110lbs≈50kg
- Calculate the total amount of amikacin needed: The doctor ordered 5 mg of amikacin per kg of body weight, so the total amount of amikacin needed is:
Totalamikacin=Doseperkg×Weightinkg=5mg/kg×50kg=250mgTotalamikacin=Doseperkg×Weightinkg=5mg/kg×50kg=250mg
- Find out how many milliliters of amikacin injection the nurse should administer: Given that the available amikacin injection is 250 mg/mL, we can calculate the volume of injection needed as follows:
Volumeofinjection=TotalamikacinConcentrationofinjection=250mg250mg/mL=1mLVolumeofinjection=ConcentrationofinjectionTotalamikacin=250mg/mL250mg=1mL
So, the nurse should administer 1 mL of amikacin injection.
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