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.
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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Related Questions
Correct Answer is B
Explanation
Leaving medication at the client's bedside is unsafe as it can lead to medication errors, missed doses, or accidental ingestion.
B. Coming back in a few minutes to administer the medication respects the client’s therapy schedule and ensures the nurse can directly observe the client taking the medication, ensuring proper administration and adherence.
C. Preparing the medication in the medication room ahead of time can be efficient but doesn’t address the need to personally administer the medication and confirm the client takes it.
D. Documenting the medication was given without actually administering it is unethical and against best practices as it assumes the client will take the medication without verification.
Correct Answer is B
Explanation
A. This right involves informing the patient about participation in research, not relevant to the patient's refusal of the medication. It is important but does not apply to the patient's immediate concern about the medication's side effect.
B. Patients have the right to refuse any medication, regardless of potential consequences, and this right must be respected. Respecting this right involves acknowledging the patient’s autonomy and addressing their concerns.
C. This right involves educating the patient about their medications, which may help them make informed decisions about their treatment. While important, it is not directly related to the patient's immediate refusal of the medication.
D. This right ensures that patients are not given medications that are not clinically indicated. It is important for preventing overmedication but is not directly related to the patient's refusal of the medication due to side effects.
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