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.

Answer and Explanation

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.

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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.

A. Platelet count 120,000/mm². B. WBC count 9,800/mm³. C. Hgb 13 mg/dL. D. Hct 42%.

Correct Answer is A

Explanation

The nurse should notify the provider because this value is lower than the normal range of 150,000 to 450,000 platelets per microliter of blood. A low platelet count can indicate a risk of bleeding or a condition such as thrombocytopenia or disseminated intravascular coagulation (DIC).

Choice B is wrong because WBC count 9,800/mm³ is within the normal range of 4,500 to 11,000 cells per microliter of blood.

Choice C is wrong because Hgb 13 mg/dL is within the normal range of 12 to 16 mg/dL for females and 14 to 18 mg/dL for males.

Choice D is wrong because Hct 42% is within the normal range of 37% to 47% for females and 42% to 52% for males.

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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?

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