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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Consulting a pharmaceutical sales representative is not the best option. While they are knowledgeable about the medications they promote, their primary role is to market their company’s products, and they may not have comprehensive information about other medications.
Choice B rationale:
While a nursing team member can be a valuable resource, they may not have the specific knowledge about the medication in question. It’s also important to remember that medication information can change frequently, and relying on another person’s knowledge may lead to errors.
Choice C rationale:
The client’s family can provide useful information about how the client has been taking the medication at home, but they are unlikely to have detailed pharmacological knowledge about the medication.
Choice D rationale:
A nursing drug guide is a reliable and up-to-date resource that provides comprehensive information about medications, including indications, contraindications, dosages, potential side effects, and interactions. Therefore, when unfamiliar with a medication, the nurse should consult a nursing drug guide.
Correct Answer is D
Explanation
Choice A rationale:
Spreading the ointment in a 10 cm² (4 in) area is not the recommended method for nitroglycerin ointment application. The ointment should be applied over a 6x inch area in a thin, uniform layer.
Choice B rationale:
Massaging the ointment into the skin is not advised. The ointment should be applied in a thin layer and left to absorb into the skin.
Choice C rationale:
Applying the ointment in a thick layer is not recommended. A thin, uniform layer is sufficient for therapeutic effect.
Choice D rationale:
Covering the administration area with plastic wrap is the correct action. This helps to keep the ointment in place and enhances absorption.
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