A nurse is collecting data from a client following his first dose of captopril.
The client's blood pressure is 88/60 mm Hg. Which of the following actions should the nurse take first?
Check blood pressure with the client standing.
Administer a 0.9% sodium chloride IV bolus.
Place the client in a supine position.
Measure blood pressure with the client sitting.
The Correct Answer is C
Choice A rationale:
Checking blood pressure with the client standing could exacerbate the client’s symptoms due to orthostatic hypotension, which is a common side effect of captopril.
Choice B rationale:
Administering a 0.9% sodium chloride IV bolus could be considered if the client’s blood pressure does not improve with positioning changes or if the client’s condition worsens.
Choice C rationale:
Placing the client in a supine position can help increase blood flow to the brain and alleviate symptoms of low blood pressure. This should be the first action taken by the nurse.
Choice D rationale:
Measuring blood pressure with the client sitting could also exacerbate symptoms due to orthostatic hypotension. It would be more appropriate after the client’s condition has stabilized.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice Arationale:
Aspiration (pulling back on the syringe before injection) is not recommended when administering enoxaparin. This could cause bruising.
Choice Brationale:
You should not massage the site following the injection as this could cause bruising.
Choice Crationale:
With enoxaparin and other low molecular weight heparins, you do not need to expel the air bubble before injecting the medication. The air bubble ensures that all the medication is delivered.
Choice D rationale:
Enoxaparin should be injected into abdominal tissue. This helps ensure proper absorption and reduces the risk of bruising.
Correct Answer is C
Explanation
Choice Arationale:
Flaxseed is a rich source of omega-3 fatty acids and can have anti-inflammatory effects. It does not have any known contraindications with SLE.
Choice B rationale:
Glucosamine is often used to support joint health. It is not contraindicated in clients with SLE and may actually provide some benefits in terms of reducing joint pain and stiffness.
Choice C rationale:
Echinacea is an herbal supplement that is often used to boost the immune system. However, in clients with autoimmune disorders like SLE, boosting the immune system can actually exacerbate the disease. Therefore, Echinacea is contraindicated in clients with SLE.
Choice Drationale:
Ginger is a common herbal supplement that is often used for its anti-inflammatory and anti-nausea effects. It does not have any known contraindications with systemic lupus erythematosus (SLE)
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