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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: Tetracycline should generally be taken on an empty stomach, as certain food and beverages, including orange juice, can interfere with its absorption. The nurse should instruct the client to take tetracycline with water and on an empty stomach unless otherwise specified by the healthcare provider.
Choice B rationale: Tetracycline is an antibiotic that can make the skin more sensitive to sunlight, leading to an increased risk of sunburn and photosensitivity reactions. To prevent these adverse effects, the nurse should instruct the client to protect their skin from sunlight while taking the medication. This includes using sunscreen, wearing protective clothing, and avoiding prolonged sun exposure. It is essential to educate the client about this potential side effect to ensure their safety and minimize skin reactions during treatment.
Choice C rationale: Tetracycline does not require routine monitoring of serum drug levels. It is an antibiotic with a well-established dosing regimen, and monitoring drug levels is not necessary for its safe and effective use.
Choice D rationale: While taking tetracycline with milk or antacids may help reduce GI irritation, it can also interfere with the absorption of the medication. Therefore, it is generally recommended to take tetracycline with water and on an empty stomach to ensure optimal absorption and effectiveness.
Correct Answer is D
Explanation
Choice A rationale: Ingestion of Wort can reduce the client's intake of sodium: This information is not directly related to the situation of a renal transplant and graft rejection. It is not the most significant finding regarding the use of St. John's Wort in this context.
Choice B rationale: Adding the herb decreases the need for corticosteroids: There is no evidence or indication that St. John's Wort can decrease the need for corticosteroids, especially in the context of a renal transplant and graft rejection.
Choice C rationale: While St. John's Wort is sometimes used as an herbal remedy for depression, the most significant information, in this case, is its potential to interact with cyclosporine and affect the client's immunosuppressive medication. The focus should be on the drug interaction and the risk it poses to the client's graft health, rather than the reason for using the herb.
Choice D rationale: The most significant information about the finding that the client has been self-administering St. John's Wort is that it can decrease plasma concentrations of cyclosporine. Cyclosporine is an immunosuppressive medication commonly used after a renal transplant to prevent graft rejection. When St. John's Wort is taken concurrently with cyclosporine, it can induce certain liver enzymes responsible for drug metabolism, leading to a decreased concentration of cyclosporine in the bloodstream. This can potentially reduce the effectiveness of cyclosporine in preventing graft rejection, putting the client's transplanted kidney at risk.
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