A nurse is collecting data from a client prior to administration of verapamil. Which of the following findings indicates a need to withhold the medication?
Blood pressure 170/82 mm Hg.
Respiratory rate 18/min.
Pulse rate 48/min.
Potassium 4 mEq/L.
The Correct Answer is C
Verapamil is a calcium channel blocker that can lower the heart rate and blood pressure. A normal pulse rate for adults is between 60 and 100 beats per minute. A pulse rate of 48/min is too low and indicates bradycardia, which can cause dizziness, fainting, or cardiac arrest. Verapamil should not be given to patients with bradycardia or heart block.
Choice A is wrong because blood pressure 170/82 mm Hg is high and verapamil can help lower it. A normal blood pressure for adults is less than 120/80 mm Hg.
Choice B is wrong because respiratory rate 18/min is normal and verapamil does not affect it. A normal respiratory rate for adults is between 12 and 20 breaths per minute.
Choice D is wrong because potassium 4 mEq/L is normal and verapamil does not affect it. A normal potassium level for adults is between 3.5 and 5.0 mEq/L.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Bleach.
According to the CDC, bleach is an effective disinfectant for environmental surfaces contaminated with blood or body fluids from a person with AIDS or other bloodborne pathogens. Bleach can kill HIV and hepatitis viruses when used in a 1:10 dilution with water.
Choice A is wrong because isopropyl alcohol is not recommended for disinfecting environmental surfaces. It can evaporate quickly and may not have enough contact time to kill the pathogens.
Choice B is wrong because chlorhexidine is an antiseptic, not a disinfectant. It is used for skin cleansing or wound irrigation, but it is not effective against spores or non-enveloped viruses.
Choice C is wrong because hydrogen peroxide is a low-level disinfectant that can be inactivated by organic matter.
It is not suitable for disinfecting surfaces contaminated with blood or body fluids.
Correct Answer is A
Explanation
Encourage the client to help care for their surgical incision. This can help the client accept the body image change and promote healing.
Choice B is wrong because suggesting that the client decide about reconstruction as soon as possible can pressure the client and interfere with their coping process.
Choice C is wrong because postponing referrals to support services until the client requests them can delay the client’s emotional recovery and increase their isolation.
Choice D is wrong because avoiding talking to the client about the surgery can indicate that the nurse is uncomfortable with the topic and discourage the client from expressing their feelings.
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