The nurse is preparing to administer a scheduled dose of labetalol orally to a client with hypertension.
The client’s vital signs are temperature 99° F (37.2 C), heart rate 48 beats/minute, respirations 16 breaths/minute, and blood pressure (BP) 150/90 mm Hg. What action should the nurse take?

Withhold the scheduled dose and notify the healthcare provider.

Administer the dose and monitor the client’s BP 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 rationale

Labetalol is a non-selective beta-blocker used to treat hypertension. The goal of labetalol administration is to reduce the blood pressure to 140/90 mmHg, and the diastolic BP must not fall below 90 mmHg. However, in this scenario, the client’s heart rate is 48 beats/minute, which is lower than the normal range (60-100 beats/minute). Administering labetalol, which can further decrease heart rate, could lead to bradycardia, a condition that can cause fainting, fatigue, or chest discomfort. Therefore, the nurse should withhold the scheduled dose and notify the healthcare provider.

Choice B rationale

While it is important to monitor the client’s BP regularly when administering labetalol, given the client’s low heart rate, administering the dose could potentially exacerbate the client’s bradycardia. Therefore, this choice is not the most appropriate action for the nurse to take in this situation.

Choice C rationale

Assessing for orthostatic hypotension before administering the dose is an important consideration when administering medications that can lower blood pressure. However, in this case, the client’s low heart rate is a more immediate concern. Therefore, this choice is not the most appropriate action for the nurse to take in this situation.

Choice D rationale

Applying a telemetry monitor could help in monitoring the client’s heart rate and rhythm. However, given the client’s current heart rate, the priority should be to withhold the medication and inform the healthcare provider.

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Correct Answer is B

Explanation

Choice A rationale

Sucralfate is not typically administered once daily, preferably at bedtime. It is usually given multiple times a day.

Choice B rationale

Sucralfate should be given on an empty stomach, at least one hour before meals and at bedtime. This is because the absorption of sucralfate can be affected by the presence of food in the stomach.

Choice C rationale

While it’s important to monitor for infections when administering any medication, there’s no specific association between sucralfate and secondary Candida infections.

Choice D rationale

Sucralfate does not typically cause electrolyte imbalances. Its main function is to form a protective barrier over the ulcer, preventing further damage from acid and pepsin.

A. Administer a second dose of naloxone. B. Prepare to assist with chest tube insertion. C. Determine Glasgow Coma Scale score. D. Initiate cardiopulmonary resuscitation (CPR). .

Correct Answer is D

Explanation

The correct answer is choice D: Initiate cardiopulmonary resuscitation (CPR).

Choice D rationale: The patient's respiratory rate of 4 breaths/minute, oxygen saturation of 75%, and unresponsiveness indicate severe respiratory depression, which requires immediate intervention. CPR is the priority action to maintain circulation and oxygenation while awaiting further interventions.

Choice A rationale: Administering a second dose of naloxone may be necessary to counteract the effects of opioids. However, in this case, the patient's condition has severely deteriorated, and immediate resuscitation efforts take priority.

Choice B rationale: Preparing to assist with chest tube insertion is not the appropriate action in this situation. Chest tube insertion is used to treat conditions like pneumothorax or pleural effusion, which are not indicated in this scenario.

Choice C rationale: Determining the Glasgow Coma Scale score is useful for assessing the patient's level of consciousness but should not be the first action in this case. Ensuring adequate circulation and oxygenation through CPR is the priority.

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The nurse is preparing to administer a scheduled dose of labetalol orally to a client with hypertension.The client’s vital signs are temperature 99° F (37.2 C), heart rate 48 beats/minute, respirations 16 breaths/minute, and blood pressure (BP) 150/90 mm Hg. What action should the nurse take?

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Naxlex Comprehensive Predictor Exams

The nurse is preparing to administer the anti-ulcer gastrointestinal agent sucralfate to a patient with peptic ulcer disease.What should be included in this patient’s care plan?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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The nurse is preparing to administer a scheduled dose of labetalol orally to a client with hypertension.
The client’s vital signs are temperature 99° F (37.2 C), heart rate 48 beats/minute, respirations 16 breaths/minute, and blood pressure (BP) 150/90 mm Hg. What action should the nurse take?