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.

Answer and Explanation

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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Correct Answer is C

Explanation

Choice A rationale:

Increased temperature is not a direct indication of naloxone’s effectiveness. Naloxone works by reversing the effects of opioids, which do not typically include fever.

Choice B rationale:

While naloxone can cause an abrupt withdrawal in opioid-dependent individuals, leading to symptoms such as hypertension, it does not typically decrease blood pressure in opioid overdose cases.

Choice C rationale:

Naloxone works by reversing the life-threatening depression of the central nervous system and respiratory system caused by an opioid overdose. Therefore, an increased respiratory rate after administration would indicate that the medication is effective.

Choice D rationale:

Naloxone reverses the effects of opioids, including pain relief. Therefore, a report of decreased pain would not indicate that the medication is effective.

A. Fever. B. Jaundice. C. Diarrhea. D. Tinnitus.

Correct Answer is B

Explanation

Choice A rationale:

Fever is not a common side effect of acetaminophen. In fact, acetaminophen is often used to reduce fever.

Choice B rationale:

Jaundice, which is a yellowing of the skin or eyes, can be a sign of liver damage, a rare but serious side effect of acetaminophen.

Choice C rationale:

Diarrhea is not a common side effect of acetaminophen.

Choice D rationale:

Tinnitus, or ringing in the ears, is not a common side effect of acetaminophen.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Correct Answer is B

Explanation

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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?