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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Free Nursing Study Resources

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.

A. Ingestion of Wort can reduce the client's intake of sodium. B. Adding the herb decrease the need for corticosteroids. C. The client probably used this herb to treat depression. D. Wort can decrease plasma concentrations of cyclosporine.

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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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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Naxlex Comprehensive Predictor Exams

Find information about a client below. Exhibits What should the nurse double-check with a second nurse? Select all that apply.

Correct Answer is ["A","C","E","G"]

Explanation

Correct Answer is D

Explanation

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?

While assessing a client who takes acetaminophen for chronic pain, the nurse observes that the client's skin looks yellow in color. Which action should the nurse take in response to this finding?

The nurse is caring for a client who has been taking ibuprofen. Which finding is most important for the nurse report to the healthcare provider?

A female client who is a vegetarian has a new prescription for warfarin. The client states she eats leafy green vegetables every day. How should the nurse respond?

The nurse is planning care for a client with major depression who is receiving a new prescription for duloxetine. Which information is most important for the nurse to obtain?

A nurse is assessing a client's ability to swallow. Which of the following, when selected by the nurse, indicates an understanding of the cranial nerve that tests the ability to swallow?

The nurse is administering the muscle relaxant baclofen by mouth (PO) to a client diagnosed with multiple sclerosis. Which intervention should the nurse implement?