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.

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Correct Answer is A

Explanation

Choice A rationale:

Dissolving the medication in 30 mL of water is the correct action. This ensures that the medication is in a suitable form for administration via an NG tube and helps prevent the tube from becoming blocked.

Choice B rationale:

Maintaining the client in the supine position during medication administration is not recommended. This position increases the risk of aspiration. Instead, the client should be in an upright position during medication administration and for at least 30 minutes afterward.

Choice C rationale:

Adding the medication to the enteral feeding formula is not recommended. This can alter the effectiveness of the medication and can also clog the feeding tube.

Choice D rationale:

Flushing the tube with 5 mL of water after administering the medication is not enough. The tube should be flushed with at least 15-30 mL of water before and after medication administration to ensure that the entire dose has been administered and to prevent clogging of the tube.

A. Flaxseed. B. Glucosamine. C. Echinacea. D. Ginger.

Correct Answer is C

Explanation

Choice Arationale:

Flaxseed is a rich source of omega-3 fatty acids and can have anti-inflammatory effects. It does not have any known contraindications with SLE.

Choice B rationale:

Glucosamine is often used to support joint health. It is not contraindicated in clients with SLE and may actually provide some benefits in terms of reducing joint pain and stiffness.

Choice C rationale:

Echinacea is an herbal supplement that is often used to boost the immune system. However, in clients with autoimmune disorders like SLE, boosting the immune system can actually exacerbate the disease. Therefore, Echinacea is contraindicated in clients with SLE.

Choice Drationale:

Ginger is a common herbal supplement that is often used for its anti-inflammatory and anti-nausea effects. It does not have any known contraindications with systemic lupus erythematosus (SLE)

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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?

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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?