A nurse is collecting data from a client prior to administering a calcium channel blocker (CCB) for treatment of hypertension. For which of the following findings should the nurse contact the provider?

Heart rate of 66/min

BP of 148/94 mm Hg

Peripheral edema of the ankles

A digoxin level of 1.2 ng/mL.

Answer and Explanation

The Correct Answer is C

(a) Heart rate of 66/min:
A heart rate of 66/min is within the normal range (60-100 bpm) and does not typically require contacting the provider before administering a calcium channel blocker. CCBs can affect heart rate, but this finding alone is not a contraindication for their use.

(b) BP of 148/94 mm Hg:
A blood pressure reading of 148/94 mm Hg indicates hypertension, which is an appropriate indication for the use of calcium channel blockers. This finding supports the use of the medication rather than requiring the provider to be contacted.

(c) Peripheral edema of the ankles:
Peripheral edema is a known side effect of calcium channel blockers. If the client is already experiencing edema, administering the medication could potentially worsen this condition. The nurse should contact the provider to discuss this finding before proceeding with the medication administration.

(d) A digoxin level of 1.2 ng/mL:
A digoxin level of 1.2 ng/mL is within the therapeutic range (0.5-2.0 ng/mL). This finding does not necessitate contacting the provider before administering a calcium channel blocker, as it does not indicate toxicity or a contraindication for CCB use

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Correct Answer is B

Explanation

A. Abdominal pain: Abdominal pain is not typically associated with respiratory acidosis. Respiratory acidosis is a condition that occurs when the lungs can’t remove enough carbon dioxide, resulting in an acidic blood pH.

B. Lethargy: Lethargy is a common symptom of respiratory acidosis. Patients may experience fatigue, especially during the daytime1. This is due to the increased carbon dioxide levels in the blood, which can cause confusion, drowsiness, and fatigue

C. Dry skin: Dry skin is not a common symptom of respiratory acidosis. The condition primarily affects the respiratory system and does not typically cause skin changes.

D. Numbness of fingers: While numbness of fingers can be a symptom of various conditions, it is not typically associated with respiratory acidosis. The primary symptoms of respiratory acidosis are related to increased carbon dioxide levels in the blood, such as lethargy and confusion.

A. An adolescent who asks to stay in the hospital because he likes the room B. A toddler who has multiple bruises on the shins of both legs and his parents report that he is clumsy C. A school-age child who cries when the nurse is giving him an injection D. A preschooler who has a BMI indicating obesity

Correct Answer is A

Explanation

Answer: A. An adolescent who asks to stay in the hospital because he likes the room

Rationale:

A) An adolescent who asks to stay in the hospital because he likes the room: This finding may indicate that the adolescent is experiencing abuse or neglect at home. A desire to remain in the hospital could suggest that the child views it as a safe space compared to their home environment, warranting further assessment for possible abuse.

B) A toddler who has multiple bruises on the shins of both legs and his parents report that he is clumsy: Bruising on the shins is common in toddlers due to normal exploratory behavior and frequent falls. The parent's explanation aligns with developmental norms, making this finding less indicative of abuse.

C) A school-age child who cries when the nurse is giving him an injection: Crying during injections is a typical reaction for school-age children and does not suggest abuse. Emotional responses to medical procedures are age-appropriate and expected.

D) A preschooler who has a BMI indicating obesity: While obesity in children may raise concerns about diet and lifestyle, it is not inherently indicative of abuse. Further evaluation may be needed for nutritional and health interventions but does not typically suggest maltreatment.

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A nurse is collecting data from a client prior to administering a calcium channel blocker (CCB) for treatment of hypertension. For which of the following findings should the nurse contact the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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