A nurse is caring for a client who received verapamil 1 hr ago and now has a blood pressure of 80/54 mm Hg. Which of the following actions should the nurse plan to take?
Administer a bolus of IV fluids.
Administer a dose of IV diphenhydramine.
Administer supplemental oxygen.
Position the client's legs in a dependent position.
The Correct Answer is A
A. Hypotension following verapamil, a calcium channel blocker, can be managed with IV fluid boluses to support blood pressure.
B. Diphenhydramine treats allergic reactions, not hypotension.
C. Oxygen may be given, but fluids are the priority to restore BP.
D. Positioning legs may help slightly, but fluids directly address the cause.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","F"]
Explanation
Reduction in edema from +3 pitting to +1 nonpitting indicates improved fluid volume status. Improved shortness of breath suggests better pulmonary and cardiac function. More energy and better sleep are signs of increased cardiac output and symptom relief. Weight loss of 3.2 kg (7 lb) in 1 week indicates successful diuresis and fluid reduction.
Reported episodes of nausea and decreased appetite and occasional dizziness indicate persistent poor condition.
Correct Answer is C
Explanation
A. Maintaining the extremity below the level of the heart may worsen the edema and is not recommended for infiltration.
B. Slowing the IV solution rate may help reduce further fluid buildup but does not address the cool, edematous site.
C. Applying a warm, moist compress helps to reduce edema and promotes absorption of infiltrated fluid.
D. Initiating a new IV distal to the initial site is not the first action to take and should only be done if the site is not salvageable.
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