The nurse prepares to administer a scheduled dose of labetalol PO to a client with hypertension. The client's vital signs are a temperature of 99° F (37.2° C), a heart rate of 48 beats/minute, respirations of 16 breaths/minute, and a blood pressure of 150/90 mm Hg. Which action should the nurse take?

Assess for orthostatic hypotension before administering the dose.

Administer the dose and monitor the client's blood pressure regularly.

Withhold the scheduled dose and notify the healthcare provider.

Apply a telemetry monitor before administering the dose.

Answer and Explanation

The Correct Answer is C

A) Assessing for orthostatic hypotension is important when administering medications that can lower blood pressure, but in this scenario, the vital signs indicate bradycardia (heart rate of 48 beats/minute), which may be a contraindication for administering labetalol. Therefore, withholding the dose and notifying the healthcare provider is the priority.

B) Administering the dose and monitoring the client's blood pressure regularly could potentially worsen bradycardia and hypotension, especially given the client's current vital signs. It is safer to withhold the dose and seek guidance from the healthcare provider.

C) Withholding the scheduled dose and notifying the healthcare provider is the most appropriate action in this situation. The client's bradycardia, along with the hypertension, raises concern about the safety of administering labetalol without further assessment and possible adjustment of the treatment plan.

D) Applying a telemetry monitor may be warranted if the client's bradycardia is of concern, but it does not address the potential risk associated with administering labetalol to a client with a heart rate of 48 beats/minute. The priority is to withhold the medication and inform the healthcare provider for further evaluation and guidance.

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Free Nursing Study Resources

Correct Answer is D

Explanation

A) Take the benzodiazepine at the same time of taking the morphine: This statement is incorrect. Benzodiazepines and morphine are both central nervous system depressants and can potentiate each other’s effects, leading to increased sedation and respiratory depression. Taking them together without proper supervision or dosage adjustment can be dangerous. Therefore, this statement indicates a misunderstanding of the medication regimen.

B) Do not drink grapefruit juice after taking morphine: While grapefruit juice can interact with certain medications by affecting their metabolism, there is no specific interaction between grapefruit juice and morphine that requires avoidance. Therefore, this statement is not directly related to the use of morphine for bone pain.

C) Watch for signs of agitation and record any insomnia: While it is important to monitor for side effects of morphine, such as agitation and insomnia, this statement does not directly relate to the management of constipation, which is a common side effect of opioid analgesics like morphine.

D) Observe bowel movement pattern and take a stool softener: This is the correct answer. Morphine is known to cause constipation as a side effect due to its action on opioid receptors in the gastrointestinal tract. Therefore, monitoring bowel movements and taking a stool softener can help prevent or alleviate constipation associated with morphine use. This statement indicates an understanding of the potential side effects of the medication and the importance of managing them appropriately.

A. Irritable bowel syndrome. B. Coronary artery disease. C. Type 2 diabetes mellitus. D. Seasonal allergic rhinitis.

Correct Answer is B

Explanation

A) Irritable bowel syndrome: While it's im’ortant to consider the client's me’ical history comprehensively, sumatriptan succinate is primarily contraindicated in clients with a history of coronary artery disease due to its potential vasoconstrictive effects.

B) Coronary artery disease: This is the correct response. Sumatriptan succinate is contraindicated in clients with a history of coronary artery disease or ischemic heart disease due to its potential to cause coronary vasospasm and increase the risk of myocardial ischemia or infarction.

C) Type 2 diabetes mellitus: While it's im’ortant to consider the client's ov’rall medical history, type 2 diabetes mellitus is not specifically contraindicated with sumatriptan succinate use.

D) Seasonal allergic rhinitis: While seasonal allergic rhinitis is relevant to the client's me’ical history, it is not directly related to the contraindications of sumatriptan succinate.

Therefore, the most crucial consideration before administering sumatriptan succinate is to determine if the client has a history of coronary artery disease or ischemic heart disease to avoid potential adverse cardiac effects.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing discharge instructions for a client with metastatic cancer who is proscribed morphine for bone pain. Which information from the client indicates to the nurse an understanding of the medication?

Correct Answer is D

Explanation

Before administering the initial dose of sumatriptan succinate to a client with a migraine headache, it is most important to determine if the client's hi’tory includes which problem?

Correct Answer is B

Explanation

A male client has been receiving the antibiotic gentamicin sulfate, IV piggyback every 12 hours for several days. Which observation by the nurse indicates that the client may be experiencing an adverse effect of gentamicin? Reference Range: White Blood Cell [5000 to 10,000/mm3 (5 to 10 x 10%)]

Six days after starting a prescription of an oral amoxicillin solution, a client calls the clinic to report the onset of a low grade fever. Which action should the nurse Implement?

A client is scheduled for a spiral computed tomography (CT) scan with contrast to evaluate for pulmonary embolism. Which information in the client’s history requires follow up by the nurse?

A client who experiences migraine headaches reports having fewer headaches since using the herbal remedy feverfew. Which information is most important for the nurse to include in a teaching plan for this client?

A client with cystitis receives a prescription for phenazopyridine. Which information should the nurse explain to the client about its therapeutic effect?

Ferrous sulfate elixir is prescribed for a client with iron deficiency anemia. Which instruction should the nurse provide this client about taking the liquid medication?

The nurse is reviewing the client’s laboratory results. Based on a client’s serum digoxin level, the client is diagnosed with digoxin toxicity. Which action should the nurse expect to implement?