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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
The first dose of the varicella vaccine is usually given when the child is between 12 to 15 months old, not after 3 years.
Choice B rationale:
Aspirin should not be given to children due to the risk of Reye’s syndrome. This syndrome is a rare but serious condition that causes swelling in the liver and brain.
Choice C rationale:
The varicella vaccine should be avoided in children who have leukemia or any other condition that weakens the immune system.
Choice D rationale:
The varicella vaccine is not contraindicated for children who are allergic to eggs. It’s some other vaccines like influenza that have this restriction.
Correct Answer is D
Explanation
Choice A rationale:
Spreading the ointment in a 10 cm² (4 in) area is not the recommended method for nitroglycerin ointment application. The ointment should be applied over a 6x inch area in a thin, uniform layer.
Choice B rationale:
Massaging the ointment into the skin is not advised. The ointment should be applied in a thin layer and left to absorb into the skin.
Choice C rationale:
Applying the ointment in a thick layer is not recommended. A thin, uniform layer is sufficient for therapeutic effect.
Choice D rationale:
Covering the administration area with plastic wrap is the correct action. This helps to keep the ointment in place and enhances absorption.
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