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A nurse is caring for a client who is receiving prazosin. The client's blood pressure is 100/60 mm Hg. Which of the following actions should the nurse take?

Administer a reversal agent

Initiate cardiac monitoring

Instruct the client to stand up slowly.

Inform the client to report urinary retention

Answer and Explanation

The Correct Answer is C

c. Instruct the client to stand up slowly.

Explanation:

The correct answer is c. Instruct the client to stand up slowly.

Prazosin is an alpha-1 adrenergic blocker used to treat hypertension and benign prostatic hyperplasia. One of the common side eﬀects of prazosin is orthostatic hypotension, which can cause a drop in blood pressure when changing positions from lying or sitting to standing.

In this scenario, the client's blood pressure is 100/60 mm Hg, which indicates hypotension. To prevent a sudden drop in blood pressure and related symptoms such as dizziness or fainting, the nurse should instruct the client to stand up slowly. This allows the body time to adjust to the change in position and minimizes the risk of orthostatic hypotension.

Option a, administering a reversal agent, is not necessary in this situation. Reversal agents are used to counteract the eﬀects of specific medications when there is a need to rapidly reverse their actions. There is no indication in the scenario that the client requires a reversal agent.

Option b, initiating cardiac monitoring, is not warranted based solely on a blood pressure reading of 100/60 mm Hg. Cardiac monitoring is typically indicated when there are specific cardiac concerns or symptoms, which are not mentioned in the scenario.

Option d, informing the client to report urinary retention, is a potential side eﬀect of prazosin but is not the most appropriate action to take in this situation. The client's blood pressure is the immediate concern, and addressing orthostatic hypotension by instructing the client to stand up slowly is the appropriate action.

By instructing the client to stand up slowly, the nurse promotes safety and minimizes the risk of orthostatic hypotension, allowing the client to adjust to the change in position and reduce the likelihood of experiencing symptoms related to low blood pressure.

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Correct Answer is D

Explanation

Answer: (D) A client has the right to view their medical record

Rationale:

A) The actual medical record belongs to the client: While clients have the right to access their medical records, the physical medical record itself typically belongs to the healthcare provider or facility that created it. The client does not own the physical document but has the right to view or obtain copies of it under HIPAA regulations.

B) A client's medical record information remains confidential, even during an emergency: While confidentiality is a core principle of the HIPAA Privacy Rule, there are specific exceptions during emergencies. For instance, healthcare providers may share information if it is necessary to provide care or if there is an imminent threat to the client or others. Thus, confidentiality can be adjusted in critical situations.

C) If the client dies, their family receives their medical record: A client’s medical records do not automatically go to their family after death. Access to a deceased person's medical records is typically granted to the executor of the estate or a legal representative, and specific legal processes must be followed. Therefore, this statement is incorrect.

D) A client has the right to view their medical record: Under the HIPAA Privacy Rule, clients have the right to access and view their medical records. They can request copies of their records, review them, and request amendments if they believe there are errors. This right is fundamental to ensuring transparency and accuracy in medical documentation.

A. Contact the provider to prescribe more pain medication for the client. B. Teach the client relaxation techniques for the treatment of acute pain. C. Document the client's reaction to the administration of medication. D. Reevaluate the client's response to the medication in 30 min.

Correct Answer is D

Explanation

The first action the nurse should take is to reevaluate the client's response to the medication in 30 min. Hydromorphone has an onset of action of 15 to 30 minutes when taken orally ¹. Therefore, it may take some time for the medication to reach its full eﬀect.

Option a is incorrect because it may not be necessary to contact the provider for more pain medication until after reevaluating the client's response to the medication.

Option b is incorrect because teaching relaxation techniques may not provide immediate relief for acute pain.

Option c is incorrect because documenting the client's reaction to the administration of medication should be done after reevaluating their response to the medication.

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A nurse is caring for a client who is receiving prazosin. The client's blood pressure is 100/60 mm Hg. Which of the following actions should the nurse take?

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