The nurse prepares to administer a scheduled dose of labetalol by mouth 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 (B/P) 150/90 mm Hg. Which action should the nurse take?

Administer the dose and monitor the client's BP regularly.

Withhold the scheduled dose and notify the healthcare provider.

Apply a telemetry monitor before administering the dose.

Assess for orthostatic hypotension before administering the dose.

Answer and Explanation

The Correct Answer is B

Choice A rationale: Administering the dose of labetalol without further assessment may not be appropriate in this situation. The client's heart rate is 48 beats/minute, which is considered bradycardia (heart rate below the normal range of 60-100 beats/minute). Bradycardia can be a potential adverse effect of labetalol, a beta-blocker. Moreover, the client's blood pressure is elevated at 150/90 mm Hg, indicating that the hypertension is not well controlled. Administering the dose without addressing the bradycardia or elevated blood pressure could potentially exacerbate these issues.

Choice B rationale: Withholding the scheduled dose of labetalol is the most appropriate action in this scenario. The client's heart rate of 48 beats/minute is considered bradycardia, which may be a side effect of labetalol or indicative of an underlying issue. Additionally, the client's blood

pressure is elevated, indicating inadequate control of hypertension. Bradycardia can reduce cardiac output and may lead to further complications. Notifying the healthcare provider is essential to obtain further instructions and address the client's bradycardia and hypertension before administering the medication.

Choice C rationale: While telemetry monitoring is appropriate for clients with certain cardiac conditions or when changes in heart rate need close observation, it may not be the most urgent action in this situation. The client's bradycardia and elevated blood pressure are concerning and require immediate attention. Telemetry monitoring may be considered later, but it does not address the immediate need to withhold the medication and seek guidance from the healthcare provider.

Choice D rationale: Orthostatic hypotension refers to a drop in blood pressure when changing positions, such as from lying down to standing up. While orthostatic hypotension is a valid concern for clients taking antihypertensive medications, it is not the primary issue in this scenario. The client's heart rate is 48 beats/minute, indicating bradycardia and the blood pressure is elevated at 150/90 mm Hg, suggesting uncontrolled hypertension. These are the main concerns that require immediate attention and further assessment before administering the labetalol dose.

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Correct Answer is C

Explanation

Choice A rationale; Family history of mental illness is important information to consider when assessing the client's overall mental health history, but it is not directly related to the immediate safety and effectiveness of duloxetine.

Choice B rationale: Weight change in the last month is relevant to monitoring for side effects of duloxetine, but it is not as critical as assessing liver function, which directly impacts the metabolism of the medication.

Choice C rationale: When planning care for a client starting on duloxetine, it is most important for the nurse to obtain liver function laboratory results. Duloxetine is primarily metabolized in the liver, and it is important to assess the client's liver function before starting the medication to ensure that the liver can process the drug effectively and safely. Clients with impaired liver function may require dose adjustments or be at higher risk for adverse effects, so obtaining liver function test results is crucial for safe medication management.

Choice D rationale: Recent use of other antidepressants is essential to avoid potential drug interactions, but it is not the most critical piece of information compared to assessing liver function, which directly affects the client's ability to process duloxetine.

A. Facial (VII) B. Trigeminal (V) C. Glossopharyngeal (IX) D. Hypoglossal (VII)

Correct Answer is C

No explanation

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The nurse prepares to administer a scheduled dose of labetalol by mouth 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 (B/P) 150/90 mm Hg. Which action should the nurse take?

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The nurse prepares to administer a scheduled dose of labetalol by mouth 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 (B/P) 150/90 mm Hg. Which action should the nurse take?