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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
A Positive Chvostek’s sign is a clinical finding associated with hypocalcemia, or low levels of calcium in the blood. It’s not directly related to glyburide usage or symptoms of anxiety and profuse sweating.
Choice B rationale:
Pitting pedal edema occurs when excess fluid builds up in the body, causing swelling. It’s not directly related to glyburide usage or symptoms of anxiety and profuse sweating.
Choice C rationale:
Decreased deep-tendon reflexes or hyporeflexia happens when your skeletal muscles have a decreased or absent reflex response. It’s not directly related to glyburide usage or symptoms of anxiety and profuse sweating.
Choice D rationale:
Decreased blood glucose level or hypoglycemia occurs when your blood sugar (glucose) level falls too low. Glyburide is an oral diabetes medicine that helps control blood sugar levels. Anxiety and profuse sweating are symptoms of low blood sugar.
Correct Answer is B
Explanation
Choice A rationale:
While a tuberculin syringe can be used for insulin administration, it’s not necessary when mixing NPH and regular insulin. Insulin syringes are typically used for this purpose.
Choice B rationale:
Injecting air into each vial before withdrawing insulin helps equalize pressure and makes it easier to draw up the insulin. This should be done before withdrawing any insulin.
Choice C rationale:
Withdrawing NPH insulin first contradicts the standard practice of drawing up insulins. The usual recommendation is to draw up short-acting (regular) insulin before intermediate-acting (NPH) insulin.
Choice D rationale:
Shaking the regular insulin vial is unnecessary and could potentially create bubbles, making it harder to draw up the correct dose of insulin.
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