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 C

Explanation

A. Verify that the client's valuables have been secured:

While securing the client's valuables is important for their safety and security during hospitalization, it does not directly address the prevention of postoperative complications.
B. Discuss a discharge date with the client:

Discussing a discharge date is part of discharge planning but does not directly address the prevention of postoperative complications.
C. Inform the client about the need for sequential compression devices:

Sequential compression devices (SCDs) are mechanical devices that help prevent venous stasis and deep vein thrombosis (DVT) by promoting circulation in the lower extremities. They are commonly used in surgical patients to reduce the risk of blood clots and related complications.
D. Review the facility's visitation policy with the client and family:

Reviewing the facility's visitation policy is important for ensuring that the client and family understand the rules and regulations regarding visitors. While visitor policies contribute to the overall well-being of the client during their hospital stay, they do not directly address the prevention of postoperative complications like the use of sequential compression devices does.

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?

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