A nurse is preparing to administer a client's antihypertensive medication. When using clinical judgment, which of the following findings indicates the nurse should collect further data from the client before administering medication?

The client reports having trouble sleeping the previous night.

The client reports dizziness when ambulating to the bathroom.

The client has a urine output of 400 mL for the past 8 hr

The client ate 60% of their breakfast.

Answer and Explanation

The Correct Answer is B

A. Trouble sleeping the previous night may not be directly related to the decision to withhold antihypertensive medication.
B. Dizziness when ambulating could indicate hypotension, which can be exacerbated by antihypertensive medication. The nurse should collect further data to ensure the patient's blood pressure is safe for medication administration.
C. Urine output is important to monitor but does not directly indicate a need to withhold antihypertensive medication unless associated with other symptoms.
D. Eating 60% of breakfast does not indicate a need to collect further data before administering antihypertensive medication.

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Correct Answer is C

Explanation

A. "Client assisted OOB, instructed to splint ABD" is clear and uses standard abbreviations (OOB: out of bed, ABD: abdomen).
B. "Urine collected for UA and C & S" is clear and uses standard abbreviations (UA: urinalysis, C & S: culture and sensitivity).
C. "Prescription received for MSO4 4.0 mg PRN pain" is problematic because "MSO4" is an ambiguous abbreviation that can be confused with other medications. It should be written as "morphine sulfate" for clarity. Additionally, the trailing zero in "4.0 mg" can lead to dosing errors; it should be written as "4 mg."
D. "12 units of regular insulin administered subcut" is clear and uses standard terminology (subcut: subcutaneous).

A. Client administered nitroglycerin 0.3 mg SL for. chest pain B. Client's skin is pale and diaphoretic C. Client's blood pressure is 182/98 mm Hg D. Client reports chest pain after mowing lawn' this morning

Correct Answer is D

Explanation

A. This statement is an objective finding, describing an action taken (administration of nitroglycerin).
B. This statement describes objective observations of the client's physical appearance.
C. This statement provides objective data about the client's blood pressure.
D. This statement reflects the client's report of symptoms, making it part of the subjective component of SOAP documentation.

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A nurse is preparing to administer a client's antihypertensive medication. When using clinical judgment, which of the following findings indicates the nurse should collect further data from the client before administering medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is evaluating the documentation of a newly licensed nurse. The nurse should identify that which of the following entries requires intervention?

Correct Answer is C

Explanation

A nurse is documenting in a client's health record using the subjective, objective, assessment, and plan (SOAP) charting model. Which of the following information should be included in the subjective component?

Correct Answer is D

Explanation

A nurse is preparing to administer a client's antihypertensive medication. When using clinical judgment, which of the following findings indicates the nurse should collect further data from the client before administering medication?

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