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.

Answer and Explanation

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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice Arationale:

Using PCA does not necessarily increase the client’s risk of toxicity. PCA allows the client to self-administer preset doses of pain medication, which can lead to better pain control with less risk of overdose.

Choice B rationale:

Diarrhea is not a common adverse effect of morphine. Constipation, not diarrhea, is a common side effect due to slowed gastrointestinal motility.

Choice Crationale:

Checking the client’s pain level every 8 hours is not sufficient when using PCA. Pain levels should be assessed more frequently, ideally before and after each administration of the medication. This allows for timely adjustments to the medication regimen if needed.

Choice D rationale:

Instructing the client’s visitors not to operate the PCA pump is crucial. Only the patient should administer doses to prevent overdose.

A. Aspirate prior to injecting the medication. B. Gently massage the site following the injection. C. Expel the air bubble before injecting the medication. D. Inject the medication into abdominal tissue.

Correct Answer is D

Explanation

Choice Arationale:

Aspiration (pulling back on the syringe before injection) is not recommended when administering enoxaparin. This could cause bruising.

Choice Brationale:

You should not massage the site following the injection as this could cause bruising.

Choice Crationale:

With enoxaparin and other low molecular weight heparins, you do not need to expel the air bubble before injecting the medication. The air bubble ensures that all the medication is delivered.

Choice D rationale:

Enoxaparin should be injected into abdominal tissue. This helps ensure proper absorption and reduces the risk of bruising.

View Question and Answer

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

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a newly licensed nurse about monitoring morphine patient-controlled analgesia (PCA). Which of the following information should the nurse include?

Correct Answer is D

Explanation

A nurse is preparing to administer enoxaparin subcutaneously to a client using a prefilled syringe. The nurse should plan to use which of the following techniques when administering this medication?

Correct Answer is D

Explanation

A nurse is preparing to administer an enteric-coated oral medication to a client who is having difficulty swallowing.Which of the following actions should the nurse take?

A nurse is collecting data from a client who is taking aspirin.Which of the following findings should the nurse report to the provider?

A nurse is collecting data from a client who has taken an overdose of oxycodone.Which of the following findings should the nurse expect?

A nurse administered ketorolac 30 mg IM to a client who is postoperative.Which of the following information should the nurse document? (Select all that apply)

A nurse is preparing to administer digoxin to a client.For which of the following findings should the nurse withhold the medication?

A nurse in an acute care facility is collecting data from a client who has received the meningococcal conjugate vaccine.The nurse should monitor the client for which of the following findings as an adverse effect of the vaccine?

A nurse is collecting data from a client who has been taking diazepam several times per day but recently ran out of the medication.Which of the following findings should the nurse recognize as a manifestation of withdrawal from diazepam?

A nurse is talking with a client who has been taking levothyroxine to treat hypothyroidism.The nurse should instruct the client to avoid taking which of the following over-the-counter medications within 4 hr of taking levothyroxine?

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?