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 B
Explanation
This statement indicates that the client has orthopnea, which is a sign of worsening heart failure and fluid overload. The nurse should intervene by assessing the client’s vital signs, oxygen saturation, lung sounds, and edema, and notifying the provider for possible diuretic adjustment.
Choice A is wrong because “I’m urinating in larger amounts.” is an expected outcome of taking furosemide, which is a loop diuretic that increases urine output and reduces fluid retention.
Choice C is wrong because “I suck on hard candy for my dry mouth.” is a harmless way to cope with the side effect of dry mouth caused by furosemide.
Choice D is wrong because “I’ve lost 3 pounds in the last week.” is a positive sign that the client is losing excess fluid and improving their heart failure
condition. A weight loss of 2 to 4 pounds per week is acceptable for clients taking diuretics.
Normal ranges for heart failure clients are:
- Blood pressure: less than 140/90 mmHg
- Heart rate: 60 to 100 beats per minute
- Respiratory rate: 12 to 20 breaths per minute
- Oxygen saturation: greater than 95%
- Weight: stable or decreasing within 2 to 4 pounds per week
Correct Answer is D
Explanation
Dysrhythmia is an abnormal heart rhythm that can be a sign of severe lithium toxicity.
Lithium toxicity can occur when a person takes too much lithium, a mood- stabilizing medication used to treat bipolar disorder and major depressive disorder.
Choice A is wrong because hypoglycemia is not a symptom of lithium toxicity. Hypoglycemia is low blood sugar that can cause symptoms such as shakiness, sweating, hunger, and confusion.
Choice B is wrong because excess salivation is not a symptom of lithium toxicity. Excess salivation can be caused by various factors, such as infections, medications, or nerve damage.
Choice C is wrong because urinary retention is not a symptom of lithium toxicity. Urinary retention is the inability to empty the bladder completely, which can cause pain, discomfort, and infection. Lithium toxicity can actually cause increased urine output, not decreased.
Normal ranges for blood lithium levels are 0.6 to 1.2 mEq/L for maintenance therapy and 0.8 to 1.5 mEq/L for acute therapy. Levels above 1.5 mEq/L can cause mild to moderate toxicity, and levels above 2.0 mEq/L can cause severe toxicity. Levels above 3.0 mEq/L are considered a medical emergency.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today