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 {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

Indicated Instructions:

Hold spironolactone for 3 days (Choice D):
- Reasoning: Captopril, an ACE inhibitor, can increase potassium levels. Spironolactone is a potassium-sparing diuretic. Holding spironolactone helps prevent hyperkalemia (high potassium levels), which can be dangerous.
Lay down if the blood pressure drops quickly after the first dose (Choice E):
- Reasoning: Captopril can cause a significant drop in blood pressure, especially after the first dose. Lying down helps prevent dizziness and fainting (orthostatic hypotension) due to the sudden decrease in blood pressure.

Contraindicated Instructions:

Increase the lantus dose by 3 units the morning of the first dose (Choice B):
- Reasoning: Adjusting insulin (Lantus) dose is not related to the administration of captopril and could potentially cause blood sugar imbalances. Such a change should be based on blood glucose monitoring, not the initiation of captopril.
Limit fluids for several days before the first dose (Choice C):
- Reasoning: Limiting fluids can lead to dehydration, which can exacerbate the hypotensive effects of captopril. Maintaining adequate hydration is important to avoid severe drops in blood pressure.
Monitor blood pressure for several hours after the first dose (Choice B):
- Reasoning: Monitoring blood pressure ensures that any significant hypotensive response (drop in blood pressure) to the initial dose of captopril is identified and managed promptly.

A. Hematemesis. B. Nausea. C. Insomnia. D. Dizziness.

Correct Answer is A

Explanation

Choice A rationale: Hematemesis refers to the vomiting of blood and is a severe and potentially life-threatening adverse effect of ibuprofen. Ibuprofen belongs to the class of nonsteroidal anti-inflammatory drugs (NSAIDs), which can cause gastrointestinal bleeding and ulcerations.

Hematemesis indicates significant gastrointestinal irritation or bleeding, and it requires immediate attention from the healthcare provider to assess and manage the client's condition.

Choice B rationale: Nausea is a common side effect of ibuprofen and other NSAIDs. While it is important to monitor and address any adverse effects experienced by the client, nausea alone is not as urgent or critical as hematemesis, which can indicate a more severe complication.

Choice C rationale: Insomnia is not directly related to the use of ibuprofen. While sleep disturbances can occur as a side effect of some medications, it is not the most important finding to report to the healthcare provider in this context.

Choice D rationale: Dizziness can be a side effect of ibuprofen, but it is not the most concerning finding in this situation. Hematemesis, which indicates potential gastrointestinal bleeding, is a more critical symptom that requires immediate attention and reporting to the healthcare provider.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits For each instruction, click to indicate whether the instructions given by the nurse are indicated or contraindicated to prepare for the client's first dose of captopril.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

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?

Correct Answer is A

Explanation

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