The healthcare provider prescribes two doses of an antihypertensive medication for a client. Before administering the second dose, the nurse obtains a blood pressure measurement of 80/50 mm Hg. Which action should the nurse take?
Position the client in a lateral lying position.
Document the blood pressure and monitor the client.
Encourage an increase in oral fluid intake.
Hold the medication and notify the healthcare provider.
The Correct Answer is D
A. Positioning the client in a lateral lying position might help with comfort but does not address the immediate concern of the low blood pressure.
B. Documenting the blood pressure and monitoring the client is important, but it does not address the need to prevent potential adverse effects from administering the medication at such a low blood pressure.
C. Encouraging an increase in oral fluid intake may be helpful in managing blood pressure, but the immediate priority should be to address the potential effects of the medication on the low blood pressure.
D. Holding the medication and notifying the healthcare provider is the appropriate action because administering the medication with a blood pressure of 80/50 mm Hg could worsen hypotension and lead to further complications. The healthcare provider should be informed to reassess the medication plan.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. It is essential for the nurse to develop self-awareness of their personal values to avoid imposing these values on the client. As an advocate, the nurse's primary role is to represent the client's wishes and ensure they are respected, regardless of the nurse's personal beliefs or values.
B. While challenging differing opinions may sometimes be necessary, it is more important to ensure the client's wishes are clearly communicated rather than simply opposing differing views.
C. Educating the client on relevant nursing literature is not the primary role of advocacy in this context. The focus should be on the client’s values and wishes rather than on influencing them with professional literature.
D. Listening to discussions is important, but the nurse's role as an advocate is to ensure the client's voice is heard during the discussions, rather than informing the client of decisions after the fact.
Correct Answer is D
Explanation
A. Power flushing with 60 mL of solution can create excessive pressure in the bladder, increasing the risk of trauma or forcing bacteria into the urinary tract. Gentle irrigation is preferred to safely remove clots and sediment without causing injury.
B. Using an infusion pump to slowly irrigate the catheter may not allow proper control of pressure and volume, which can damage the bladder mucosa. Manual irrigation allows the nurse to assess resistance and stop if obstruction or discomfort occurs.
C. Clamping the catheter for 30 minutes before irrigation can increase bladder pressure and cause discomfort or potential reflux of urine into the kidneys. Routine pre-irrigation clamping is not recommended unless specifically ordered for retention management.
D. Using a sterile syringe with 20 mL of normal saline allows controlled, gentle irrigation to remove clots and sediment. Sterile technique reduces the risk of introducing pathogens, and the small volume minimizes bladder trauma while effectively clearing the catheter.
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