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

Coughing while eating after a stroke may be caused by dysphagia, a swallowing disorder that can lead to aspiration, pneumonia and infection. A speech-language pathologist can assess and treat dysphagia and help the client improve their swallowing function.

Choice B is wrong because fine motor tremors are not related to speech or language problems.

They may be caused by damage to the cerebellum or basal ganglia, parts of the brain that control movement and coordination.

Choice C is wrong because facial flushing is not related to speech or language problems.

It may be caused by high blood pressure, fever, anxiety or other conditions.

Choice D is wrong because urinary incontinence is not related to speech or language problems.

It may be caused by damage to the spinal cord, bladder, pelvic floor muscles or nerves that control urination.

A. A client who is 2 days postpartum and whose fundus is 2 to 4 cm below the umbilicus. B. A client who is 3 days postpartum and has not had a bowel movement since prior to admission. C. A client who is 4 days postpartum and has lochia serosa. D. A client who is 1 day postpartum and has not voided in 8 hr.

Correct Answer is D

Explanation

A client who is 1 day postpartum and has not voided in 8 hr. This client is at risk of urinary retention, bladder distension, and infection due to the effects of epidural anesthesia, perineal trauma, and fluid shifts after delivery. The nurse should assess the client’s bladder and catheterize if necessary.

Choice A is wrong because a client who is 2 days postpartum and whose fundus is 2 to 4 cm below the umbilicus is showing a normal finding.

The fundus should descend about 1 to 2 cm per day after delivery and be nonpalpable by day 10.

Choice B is wrong because a client who is 3 days postpartum and has not had a bowel movement since prior to admission is not uncommon.

Constipation is a common problem after delivery due to decreased peristalsis, dehydration, and fear of pain.

The nurse should encourage fluid intake, fiber intake, and early ambulation to promote bowel function.

Choice C is wrong because a client who is 4 days postpartum and has lochia serosa is also showing a normal finding.

Lochia serosa is the pinkish-brown discharge that occurs from day 4 to 10 after delivery.

It consists of old blood, serum, leukocytes, and tissue debris.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is recovering from a recent stroke. Which of the following findings should indicate to the nurse the need for a referral to a speech-language pathologist?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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