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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Those with allergies to chamomile, ragweed, or yarrow should not take feverfew because feverfew belongs to the Asteraceae/Compositae family, which includes these plants. Individuals allergic to these plants may experience allergic reactions to feverfew, such as skin rashes, swelling, and difficulty breathing. It is crucial to avoid feverfew in these cases to prevent severe allergic reactions.
Choice B reason:
Feverfew may interact with aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs), but this is not the most critical information compared to potential allergic reactions. Feverfew can inhibit platelet aggregation, which may increase the risk of bleeding when taken with NSAIDs or aspirin. However, the primary concern remains the potential for severe allergic reactions in sensitive individuals.
Choice C reason:
Abdominal pain, gas, nausea, vomiting, and diarrhea can occur when taking feverfew, but these side effects are generally mild and manageable. While it is important to inform clients about possible gastrointestinal side effects, the risk of allergic reactions in individuals sensitive to chamomile, ragweed, or yarrow is more critical.
Choice D reason:
Increased anxiety and nervousness have been reported by those taking feverfew, but these side effects are less common and typically not severe. The primary concern should be the potential for allergic reactions, which can be life-threatening.
Correct Answer is D
Explanation
Choice A reason:
Decreased episodes of incontinence are not a relevant outcome of administering zolpidem. Zolpidem is a sedative-hypnotic medication primarily used to treat insomnia by enhancing the activity of GABA, an inhibitory neurotransmitter. It does not affect urinary function or bladder control. Incontinence may be caused by other factors such as aging, prostate problems, or urinary tract infections, but it is not influenced by zolpidem.
Choice B reason:
Improved ability to concentrate is not a pertinent outcome of administering zolpidem. This medication does not enhance cognitive function or attention span. In fact, zolpidem may impair memory and cause daytime drowsiness or confusion in some patients. Its primary function is to induce sleep, not to improve concentration.
Choice C reason:
Exhibiting fewer emotional outbursts is not a significant outcome of administering zolpidem. This medication does not affect mood or behavior. In some cases, zolpidem may cause paradoxical reactions such as agitation, aggression, or hallucinations, especially in older adults. Therefore, it is not used to manage emotional outbursts.
Choice D reason:
Sleeps soundly through the night is the desired outcome of administering zolpidem. This medication is specifically designed to treat sleep problems, particularly difficulty falling asleep or staying asleep. By enhancing the activity of GABA, zolpidem helps induce and maintain sleep, which is the primary goal when prescribing this medication to patients with insomnia.
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