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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Muscle strength and tone are important assessments but are not directly related to the safe use of a heating pad.
B. The rebound phenomenon, where the effects of heat application reverse after prolonged exposure, is a consideration, but not as crucial as assessing for neurosensory impairment.
C. Limitations to range of motion may be important for mobility assessments but are less relevant to the safe application of heat therapy.
D. Assessing the degree of neurosensory impairment is most important before applying a heating pad. If the client has impaired sensation, they may not be able to detect if the heating pad is too hot, which could lead to burns or other injuries.

A. "I can only give medical information to the client with an approved interpreter." B. "The healthcare provider will share this information with you." C. "I'm sorry, but your sibling's medical information is none of your business." D. "I can give you those results as soon as I get them back from the lab."

Correct Answer is A

Explanation

A. Providing medical information to a family member who is not an approved interpreter may breach confidentiality and violate hospital policy. The nurse should ensure that communication is handled through approved channels to protect patient privacy.
B. While the healthcare provider will eventually share information with the client, the nurse should address the immediate need for proper communication with an approved interpreter.
C. This response is dismissive and does not address the issue of language barriers and the need for proper interpretation. It is important to handle language barriers professionally and respectfully.
D. The nurse should follow protocol for communication and interpretation, rather than making promises about when information will be provided.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which assessment is most important for the nurse to perform prior to the application of a heating pad?

Correct Answer is D

Explanation

A client, who speaks very little English, is being seen in the emergency department following an automobile accident. The client's sibling offers to act as an interpreter and asks about the laboratory results. Which response is best for the nurse to provide?

Correct Answer is A

Explanation

An older adult client is admitted to the medical unit following a fall at home. While undressing the client, the nurse observes that the client is wearing an adult diaper and skin breakdown is obvious over the sacral area. Which action should the nurse implement first?

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