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 A

Explanation

Choice A rationale:

Levalbuterol is a bronchodilator that relaxes muscles in the airways and increases air flow to the lungs. Therefore, a decrease in wheezing is a therapeutic effect of the medication, making this the correct choice.

Choice B rationale:

While levalbuterol can cause an increase in respiratory rate as a side effect, it is not considered a therapeutic effect of the medication. The primary goal of levalbuterol is to improve breathing by relaxing the muscles of the airways, not to increase respiratory rate.

Choice C rationale:

Levalbuterol does not directly affect nausea. It is primarily used to treat conditions related to breathing such as asthma and chronic obstructive pulmonary disease.

Choice D rationale:

An increased heart rate is a potential side effect of levalbuterol, not a therapeutic effect.

A. Remind the client to change positions slowly. B. Prepare the client's medication. C. Record the client's urinary output. D. Review the client's electrolyte levels.

Correct Answer is D

Explanation

Choice A rationale:

While reminding the client to change positions slowly is important to prevent orthostatic hypotension, it is not the priority before administering furosemide.

Choice B rationale:

Preparing the client’s medication is an important step, but it should be done after reviewing the client’s electrolyte levels.

Choice C rationale:

Recording the client’s urinary output is important when administering furosemide, a diuretic, but it is not the priority action.

Choice D rationale:

Reviewing the client’s electrolyte levels is crucial before administering furosemide because it can cause electrolyte imbalances, including low potassium levels, which can lead to serious cardiac complications.

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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

A nurse is collecting data from a client who received levalbuterol 30 min ago.Which of the following findings should the nurse identify as a therapeutic effect of the medication?

Correct Answer is A

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Correct Answer is D

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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?