A nurse is collecting data from a client prior to administering a calcium channel blocker (CCB) for treatment of hypertension. For which of the following findings should the nurse contact the provider?

Heart rate of 66/min

BP of 148/94 mm Hg

Peripheral edema of the ankles

A digoxin level of 1.2 ng/mL.

Answer and Explanation

The Correct Answer is C

(a) Heart rate of 66/min:
A heart rate of 66/min is within the normal range (60-100 bpm) and does not typically require contacting the provider before administering a calcium channel blocker. CCBs can affect heart rate, but this finding alone is not a contraindication for their use.

(b) BP of 148/94 mm Hg:
A blood pressure reading of 148/94 mm Hg indicates hypertension, which is an appropriate indication for the use of calcium channel blockers. This finding supports the use of the medication rather than requiring the provider to be contacted.

(c) Peripheral edema of the ankles:
Peripheral edema is a known side effect of calcium channel blockers. If the client is already experiencing edema, administering the medication could potentially worsen this condition. The nurse should contact the provider to discuss this finding before proceeding with the medication administration.

(d) A digoxin level of 1.2 ng/mL:
A digoxin level of 1.2 ng/mL is within the therapeutic range (0.5-2.0 ng/mL). This finding does not necessitate contacting the provider before administering a calcium channel blocker, as it does not indicate toxicity or a contraindication for CCB use

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Correct Answer is D

Explanation

(A) Develop client-specific goals and outcomes: While this is an important step in the nursing process, it is not the first step. Before developing goals and outcomes, the nurse needs to understand the client’s situation, which in this case involves determining the nature of the client’s grief.

(B) Incorporate the treatment into the client’s care: Incorporating treatment into the client’s care is part of the implementation phase of the nursing process. Before this step, the nurse needs to assess the client’s condition and plan the care, which includes understanding the nature of the client’s grief.

(C) Determine whether coping strategies were successful: Determining the success of coping strategies is part of the evaluation phase of the nursing process. This is typically done after the implementation of care and treatment. It is not the first step in caring for a client experiencing grief.

(D) Establish whether the client’s grieving is healthy or complicated: This is the most appropriate answer. The first step in the nursing process is assessment. For a client experiencing grief, this would involve establishing whether the client’s grieving is healthy (a normal response to loss) or complicated (prolonged or more intense grief that may require additional support or intervention). This understanding will guide the subsequent steps of the nursing process, including planning care and setting goals.

A. Kernig's sign B. Brudzinski's sign C. Chvostek's sign D. Cullen's sign

Correct Answer is C

Explanation

(A) Kernig’s sign: Kernig’s sign is a clinical sign in which severe stiffness of the hamstrings causes an inability to straighten the leg when the hip is flexed to 90 degrees. It is commonly associated with meningitis, not hypocalcemia.

(B) Brudzinski’s sign: Brudzinski’s sign is a symptom of meningitis. It is not associated with hypocalcemia.

(C) Chvostek’s sign: This is the most appropriate answer. Chvostek’s sign is a clinical sign of existing nerve hyperexcitability (tetany) seen in hypocalcemia. It refers to an abnormal reaction to the stimulation of the facial nerve.

(D) Cullen’s sign: Cullen’s sign is a medical term referring to superficial edema and bruising in the subcutaneous fatty tissue around the umbilicus. It is not associated with hypocalcemia.

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A nurse is collecting data from a client prior to administering a calcium channel blocker (CCB) for treatment of hypertension. For which of the following findings should the nurse contact the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning to use the nursing process to care for a client who is experiencing grief. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

A nurse is assisting with the care of a client who has hypocalcemia. For which of the following signs should the nurse monitor?

Correct Answer is C

Explanation

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