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 Arationale:

The statement about taking the medication with food is incorrect. Nitroglycerin sublingual tablets should not be taken with food. They work much faster when absorbed through the lining of the mouth.

Choice B rationale:

The statement that the medication can slow the heart rate is incorrect. Nitroglycerin does not slow the heart rate. In fact, it can cause a reflex tachycardia, where the heart rate increases.

Choice C rationale:

The statement that the effects of the medication should be felt within 5 minutes is correct. This indicates an understanding of the instructions.

Choice Drationale:

Taking the medication every 10 minutes until the pain goes away is incorrect. Nitroglycerin sublingual tablets usually give relief in 1 to 5 minutes. However, if the pain is not relieved, a second tablet can be taken 5 minutes after the first tablet. If the pain continues for another 5 minutes, a third tablet may be used. Taking the medication every 10 minutes could lead to an overdose.

A. Tell the client they can have another dose of ketorolac in 3 hr. B. Administer oxycodone 5 mg orally. C. Give acetaminophen 650 mg rectally. D. Document that the client is exhibiting drug-seeking behaviors.

Correct Answer is B

Explanation

Choice A rationale:

Ketorolac is a non-steroidal anti-inflammatory drug (NSAID) used for pain relief after surgery. However, it’s not typically administered every 3 hours. Overuse can lead to serious side effects.

Choice B rationale:

If the client’s pain level remains high after receiving ketorolac, administering an opioid medication like oxycodone may be appropriate.

Choice C rationale:

While acetaminophen can be used for pain relief, rectal administration is not typically the first choice for postoperative pain management.

Choice D rationale:

It’s inappropriate to label a patient as exhibiting drug-seeking behaviors simply because their reported pain level remains high after medication. Pain is subjective and should be addressed appropriately.

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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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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?