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 A
Explanation
Choice A rationale:
An apical pulse of 54/min is below the normal range for adults. Digoxin, a cardiac medication, can lower the heart rate. Therefore, it’s crucial to hold the medication if the resting pulse for an adult is less than 60 bpm. This is to prevent further lowering of the heart rate which could lead to bradycardia, a potentially dangerous condition.
Choice B rationale:
A respiratory rate of 14/min is within the normal adult range of 12-20 breaths per minute. This would not be a reason to withhold digoxin.
Choice C rationale:
A blood pressure (BP) of 179/89 mm Hg indicates hypertension, which is not a direct contraindication for digoxin. However, it’s important to monitor BP levels in clients taking digoxin as the medication can affect blood pressure.
Choice D rationale:
A temperature of 37.8° C (100° F) is slightly elevated but would not be a reason to withhold digoxin unless it’s indicative of an underlying infection that needs to be addressed first.
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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