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 C
Explanation
Choice A rationale: Checking the capillary glucose level is not relevant to the observation of yellow skin color. Jaundice is related to liver function, not glucose levels.
Choice B rationale: Oxygen saturation measurement is not relevant to the observation of yellow skin color. It is used to assess the oxygen-carrying capacity of the blood, not liver function.
Choice C rationale: Yellow discoloration of the skin (jaundice) can be indicative of liver dysfunction or damage. Since the client takes acetaminophen for chronic pain, which is metabolized in the liver, the nurse should be concerned about potential hepatotoxicity. Reporting the findings to the healthcare provider is essential for further evaluation and management.
Choice D rationale: Reducing the medication dose is not appropriate without further evaluation and guidance from the healthcare provider. Jaundice may indicate liver dysfunction, and altering the medication without professional assessment could be unsafe.
Correct Answer is D
Explanation
Choice A rationale: Probenecid does not prevent kidney stones. Its primary function is to increase the excretion of uric acid in the urine.
Choice B rationale: Probenecid does not affect the strength of the urine stream. Its action is specific to uric acid excretion.
Choice C rationale: Probenecid is not used to alleviate pain and burning during urination. Its main indication is for gout and hyperuricemia.
Choice D rationale: Probenecid is a uricosuric drug used to treat gout and hyperuricemia. It works by inhibiting the reabsorption of uric acid in the kidneys, which promotes its excretion in the urine. By increasing uric acid excretion, probenecid helps to reduce the concentration of uric acid in the blood and prevent gout attacks.
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