A client who receives multiple antihypertensive medications experiences syncope due to a drop in blood pressure to 70/40 mm Hg. Which is the rationale for the nurse's decision to hold the client's scheduled antihypertensive medications?

Increased urinary clearance of the multiple medications has produced diuresis and lowered the blood pressure.

The synergistic effect of the multiple medications has resulted in drug toxicity and hypotension.

The antagonistic interaction among the various blood pressure medications has reduced their effectiveness.

The additive effect of multiple medications has caused the blood pressure to drop too low.

Answer and Explanation

The Correct Answer is D

Choice A reason: Increased urinary clearance of the multiple medications is not the cause of the client's syncope. Diuresis is a common side effect of some antihypertensive medications, such as diuretics, but it does not lower the blood pressure to a dangerous level. The nurse should monitor the client's fluid and electrolyte balance and urine output, but it is not the priority action in this situation.

Choice B reason: The synergistic effect of the multiple medications is not the cause of the client's syncope. Synergism is when two or more drugs work together to produce a greater effect than the sum of their individual effects. This can be beneficial or harmful, depending on the drugs and the doses. The nurse should check the client's medication history and avoid prescribing drugs that have a negative synergistic effect, but it is not the most likely explanation for the client's hypotension.

Choice C reason: The antagonistic interaction among the various blood pressure medications is not the cause of the client's syncope. Antagonism is when two or more drugs work against each other to reduce or cancel out their effects. This can decrease the effectiveness of the treatment and increase the risk of complications. The nurse should check the client's medication history and avoid prescribing drugs that have a negative antagonistic effect, but it is not the most likely explanation for the client's hypotension.

Choice D reason: The additive effect of multiple medications is the most likely cause of the client's syncope. Additivity is when two or more drugs have a similar effect and their combined effect is equal to the sum of their individual effects. This can lower the blood pressure too much and cause symptoms such as dizziness, fainting, and shock. The nurse should hold the client's scheduled antihypertensive medications and notify the healthcare provider. The nurse should also monitor the client's vital signs, level of consciousness, and perfusion.

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Correct Answer is B

Explanation

Choice A reason: Measuring the client's urinary output is not the most appropriate action for the nurse to take. Although urinary output is an important indicator of renal function, it is not related to the color change of the urine. The nurse should monitor the client's fluid balance as part of the routine care, but it is not a priority.

Choice B reason: Explaining the color change is normal is the most appropriate action for the nurse to take. Carbidopa/levodopa can cause the urine to become dark brown or black, which is a harmless side effect. The nurse should reassure the client that this is not a sign of a serious problem and does not affect the effectiveness of the medication.

Choice C reason: Obtaining a specimen for a urine culture is not the most appropriate action for the nurse to take. A urine culture is used to diagnose a urinary tract infection (UTI), which is characterized by symptoms such as dysuria, frequency, urgency, and hematuria. The color change of the urine due to carbidopa/levodopa is not indicative of a UTI. The nurse should obtain a urine culture only if the client has signs or symptoms of a UTI.

Choice D reason: Encouraging an increase in oral intake is not the most appropriate action for the nurse to take. Although adequate hydration is important for the client's health, it is not related to the color change of the urine. The nurse should encourage the client to drink enough fluids to prevent dehydration, but it is not a priority.

A. Stool color and character. B. Serum electrolytes and ammonia. C. Serum hepatic enzymes. D. Fingerstick glucose.

Correct Answer is B

Explanation

Choice A reason: This is not the best assessment for the nurse to use to evaluate the client's therapeutic response to lactulose. Stool color and character may change as a result of lactulose administration, as it is a laxative that lowers the pH of the colon and promotes the excretion of ammonia. However, these changes are not indicative of the effectiveness of lactulose in reducing the ammonia levels in the blood, which is the main goal of the therapy.

Choice B reason: This is the best assessment for the nurse to use to evaluate the client's therapeutic response to lactulose. Serum electrolytes and ammonia are directly affected by lactulose administration, as it lowers the blood ammonia levels by converting it to ammonium and facilitating its elimination in the stool. The nurse should monitor the serum electrolytes and ammonia levels regularly to assess the efficacy and safety of lactulose therapy, as well as to adjust the dosage as needed.

Choice C reason: This is not the best assessment for the nurse to use to evaluate the client's therapeutic response to lactulose. Serum hepatic enzymes are markers of liver function and damage, and they may be elevated in clients with hepatic encephalopathy due to cirrhosis or other liver disorders. However, lactulose does not affect the hepatic enzymes directly, and it does not reverse the underlying liver disease. The nurse should monitor the serum hepatic enzymes to assess the progression and severity of the liver condition, but not to evaluate the response to lactulose.

Choice D reason: This is not the best assessment for the nurse to use to evaluate the client's therapeutic response to lactulose. Fingerstick glucose is a measure of blood glucose levels, and it may be altered in clients with hepatic encephalopathy due to impaired glucose metabolism by the liver. However, lactulose does not affect the blood glucose levels directly, and it does not improve the liver's ability to regulate glucose. The nurse should monitor the fingerstick glucose to assess the risk of hypoglycemia or hyperglycemia, but not to evaluate the response to lactulose.

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A client who receives multiple antihypertensive medications experiences syncope due to a drop in blood pressure to 70/40 mm Hg. Which is the rationale for the nurse's decision to hold the client's scheduled antihypertensive medications?

Nursing Test Bank

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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