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 {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"}}
Explanation
Choice A rationale: Indicated. This is important for a client with type 1 diabetes, as counting carbohydrates helps in calculating the appropriate insulin dose and maintaining glycemic control.
Choice B rationale: Non-essential. The client is already admitted to the surgical floor and does not require restarting the IV fluids unless there is a specific medical indication.
Choice C rationale: Contraindicated. Insulin doses should be prescribed by a healthcare provider based on the patient's blood glucose levels and individual insulin requirements. The nurse should follow the prescribed insulin orders and not administer insulin without an order.
Choice D rationale: Indicated. Insulin glargine is a long-acting basal insulin used to provide a steady background insulin level throughout the day. The nurse should administer the prescribed insulin glargine dose as ordered.
Choice E rationale: Contraindicated. Insulin lispro is a rapid-acting insulin, and insulin glargine is a long-acting insulin. Mixing different types of insulin in one syringe can alter their pharmacokinetics and lead to inconsistent blood glucose control. Insulin lispro and insulin glargine should be administered separately.
Correct Answer is ["A","C","E","G"]
Explanation
Choice A rationale: This is essential to ensure that the insulin is not discolored or cloudy, as these changes could indicate a problem with the insulin's stability or effectiveness.
Choice B rationale: While it is essential to have a complete history and physical for proper patient care, double-checking this with another nurse is not necessary in the immediate administration of insulin lispro.
Choice C rationale: Double-checking the dose of insulin in the syringe is crucial to avoid medication errors and ensure that the correct amount is being administered to the patient.
Choice D rationale: The sliding scale order is not mentioned in the information provided, and since it is not part of the immediate insulin administration, it does not need to be double-checked in this context.
Choice E rationale: Checking the expiration date is necessary to ensure that the insulin is still within its usable period. Using expired insulin can lead to reduced potency and potentially ineffective blood sugar control.
Choice F rationale: The information provided in the nurse's notes does not indicate that insulin administration is due at a specific site (e.g., subcutaneous injection). Therefore, there is no need for a second nurse to double-check the site at this moment. However, it's important for the administering nurse to choose the appropriate site following the facility's guidelines and rotate injection sites to prevent lipodystrophy.
Choice G rationale: Different types of insulin come in different concentrations (e.g., U-100, U-200). It's important to confirm that the correct concentration is being used to ensure accurate dosing.
Choice H rationale: The nurse should verify that the insulin to be administered is indeed insulin lispro, as indicated in the medication order. Administering the wrong type of insulin can have significant implications for the patient's blood sugar control.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.