A nurse is caring for a client who has chronic hypertension. The client's morning vital signs include BP 140/80 mm Hg, heart rate 54/min, and respiratory rate 18/min. Which of the following medications should the nurse plan to withhold?

Hydrochlorothiazide

Lisinopril

Atenolol

Aspirin

Answer and Explanation

The Correct Answer is C

A. Hydrochlorothiazide does not affect heart rate and can be safely given.
B. Lisinopril does not cause bradycardia.
C. Atenolol is a beta-blocker that slows heart rate; withholding is necessary for bradycardia.
D. Aspirin does not influence heart rate and is not contraindicated.

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Correct Answer is A

Explanation

A. Use the Z-track technique to administer the medication.: The Z-track technique prevents irritation by sealing the medication within the muscle tissue.
B. Administer the medication with a 27-gauge 1/2-inch needle.: IM injections require a longer needle, typically 1–1.5 inches, and a larger gauge, such as 21–25.
C. Inject the medication at least 5 cm (2 in) from the umbilicus.: This is relevant for subcutaneous injections, not IM injections.
D. Give the medication without aspirating prior to injection.: Aspiration is not always required for IM injections but is often practiced for safety when administering certain medications.

A. Tachycardia B. Sedation C. Dilated pupils D. Tachypnea

Correct Answer is B

Explanation

A. Tachycardia: Bradycardia, rather than tachycardia, is more typical of opioid toxicity.
B. Sedation: Oxycodone toxicity causes CNS depression, resulting in sedation, respiratory depression, and pinpoint pupils.
C. Dilated pupils: Pinpoint pupils are a classic sign of opioid toxicity.
D. Tachypnea: Respiratory depression, rather than tachypnea, is expected in opioid toxicity.

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A nurse is caring for a client who has chronic hypertension. The client's morning vital signs include BP 140/80 mm Hg, heart rate 54/min, and respiratory rate 18/min. Which of the following medications should the nurse plan to withhold?

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