Administer a scheduled dose of labetalol PO to a client with hypertension. The client’s temperature is 99°F (37.2°C), a heart rate of 48 beats per minute, respirations of 16 breaths per minute, and a blood pressure of 150/90 mm Hg. Which action should the nurse take?

Withhold the scheduled dose and notify the healthcare provider.

Administer the dose and monitor the client’s blood pressure regularly.

Assess for orthostatic hypotension before administering the dose.

Apply a telemetry monitor before administering the dose.

Answer and Explanation

The Correct Answer is A

Choice A reason: Withholding the scheduled dose and notifying the healthcare provider is the correct action because the client’s heart rate is significantly low at 48 beats per minute. Labetalol, a beta-blocker, can further reduce the heart rate, potentially leading to bradycardia or other cardiac complications. It is crucial to inform the healthcare provider to reassess the medication regimen and ensure the client’s safety.

Choice B reason: Administering the dose and monitoring the client’s blood pressure regularly is not advisable in this scenario. Although monitoring blood pressure is important, the primary concern here is the client’s low heart rate. Administering labetalol could exacerbate bradycardia, leading to severe complications.

Choice C reason: Assessing for orthostatic hypotension before administering the dose is a good practice but not the most critical action in this situation. The client’s low heart rate poses a more immediate risk than orthostatic hypotension. Therefore, withholding the medication and notifying the healthcare provider is a higher priority.

Choice D reason: Applying a telemetry monitor before administering the dose is useful for continuous cardiac monitoring, but it does not address the immediate concern of the client’s low heart rate. The priority should be to withhold the medication and consult the healthcare provider to prevent potential bradycardia.

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Correct Answer is A

Explanation

Choice A Reason

Morphine, an opioid analgesic, is commonly prescribed for severe pain management, such as in cases of metastatic cancer. One of the well-known side effects of morphine is constipation. This occurs because opioids slow down gastrointestinal motility, leading to harder and less frequent stools. Therefore, it is crucial for patients taking morphine to monitor their bowel movements and use stool softeners or laxatives as needed to prevent constipation. This choice indicates that the client understands the importance of managing this common side effect, which can significantly impact their comfort and quality of life.

Choice B Reason

Grapefruit juice is known to interact with various medications by inhibiting the cytochrome P450 3A4 (CYP3A4) enzyme in the liver, which can lead to increased blood levels of certain drugs. However, morphine is primarily metabolized by the liver enzyme UGT2B7, not CYP3A4. Therefore, grapefruit juice does not significantly affect morphine metabolism. This choice reflects a misunderstanding of the specific interactions relevant to morphine.

Choice C Reason

Taking a benzodiazepine at the same time as morphine can be dangerous due to the risk of additive central nervous system (CNS) depression. Both morphine and benzodiazepines can cause sedation, respiratory depression, and impaired cognitive and motor functions. Concurrent use increases the risk of severe side effects, including potentially life-threatening respiratory depression. This choice indicates a lack of understanding of the risks associated with combining these medications.

Choice D Reason

While it is important to monitor for signs of agitation and insomnia, these are not the primary concerns associated with morphine use. Morphine is more likely to cause sedation rather than agitation, and insomnia is not a common side effect. This choice does not reflect a comprehensive understanding of the primary side effects and necessary precautions related to morphine use.

A. Potassium. B. Calcium. C. Phosphate. D. ph

Correct Answer is C

Explanation

Choice A reason: Potassium levels are not directly affected by calcium acetate. Calcium acetate is primarily used to manage hyperphosphatemia in patients with CKD by binding to dietary phosphate and preventing its absorption1. Therefore, a decrease in potassium levels would not indicate the effectiveness of calcium acetate.

Choice B reason: Calcium acetate can actually increase calcium levels in the blood, especially if taken in high doses or if the patient has other sources of calcium intake. Monitoring calcium levels is important to avoid hypercalcemia, but a decrease in calcium levels is not the desired effect of this medication.

Choice C reason: Calcium acetate is used to reduce serum phosphate levels in patients with CKD. It works by binding to dietary phosphate in the gastrointestinal tract, forming insoluble calcium phosphate, which is then excreted in the stool. A decrease in serum phosphate levels indicates that the medication is effectively reducing phosphate absorption and managing hyperphosphatemia.

Choice D reason: The pH level of the blood is not directly influenced by calcium acetate. While maintaining acid-base balance is important in CKD management, the primary goal of calcium acetate therapy is to control phosphate level. Therefore, changes in blood pH are not a measure of the medication’s effectiveness.

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Administer a scheduled dose of labetalol PO to a client with hypertension. The client’s temperature is 99°F (37.2°C), a heart rate of 48 beats per minute, respirations of 16 breaths per minute, and a blood pressure of 150/90 mm Hg. Which action should the nurse take?

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Naxlex Comprehensive Predictor Exams

The nurse is providing discharge instructions for a client with metastatic cancer who is prescribed morphine for bone pain. Which information from the client indicates to the nurse an understanding of the medication?

Correct Answer is A

Explanation

A client with chronic kidney disease (CKD) is receiving calcium acetate 667 mg PO. A decrease in which blood value indicates to the nurse that the medication is having the desired effect?

Correct Answer is C

Explanation

Administer a scheduled dose of labetalol PO to a client with hypertension. The client’s temperature is 99°F (37.2°C), a heart rate of 48 beats per minute, respirations of 16 breaths per minute, and a blood pressure of 150/90 mm Hg. Which action should the nurse take?

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