A nurse is collecting data from a client prior to administration of verapamil. Which of the following findings indicates a need to withhold the medication?

Blood pressure 170/82 mm Hg.

Respiratory rate 18/min.

Pulse rate 48/min.

Potassium 4 mEq/L.

Answer and Explanation

The Correct Answer is C

Verapamil is a calcium channel blocker that can lower the heart rate and blood pressure. A normal pulse rate for adults is between 60 and 100 beats per minute. A pulse rate of 48/min is too low and indicates bradycardia, which can cause dizziness, fainting, or cardiac arrest. Verapamil should not be given to patients with bradycardia or heart block.

Choice A is wrong because blood pressure 170/82 mm Hg is high and verapamil can help lower it. A normal blood pressure for adults is less than 120/80 mm Hg.

Choice B is wrong because respiratory rate 18/min is normal and verapamil does not affect it. A normal respiratory rate for adults is between 12 and 20 breaths per minute.

Choice D is wrong because potassium 4 mEq/L is normal and verapamil does not affect it. A normal potassium level for adults is between 3.5 and 5.0 mEq/L.

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Correct Answer is B

Explanation

Moist heat can help reduce pain and stiffness in the joints by increasing blood flow and relaxing the muscles. Moist heat can be applied using warm compresses, heating pads, or warm baths.

Choice A is wrong because using a recliner when sitting for long periods can increase pressure on the knees and decrease circulation. A better option is to use a straight-backed chair with a footstool.

Choice C is wrong because sleeping on a soft mattress can cause poor alignment of the spine and joints, which can worsen pain and mobility. A firm mattress is recommended for clients with osteoarthritis.

Choice D is wrong because placing large pillows under the knees when lying in bed can limit the range of motion of the knees and cause contractures. A small pillow under the knees can provide some support and comfort, but it should not be too large or too high.

A. Assist the client to a prone position. B. Ask the client to empty their bladder. C. Instruct the client to douche. D. Place the client’s arms over their head.

Correct Answer is B

Explanation

Ask the client to empty their bladder.

This is because a full bladder can interfere with the pelvic examination and cause discomfort to the client. The nurse should also instruct the client to avoid douching, using tampons, vaginal medications, sprays, powders, birth control foam, cream, or jelly for at least 24 hours before the exam.

Choice A is wrong because the client should be placed in a lithotomy position, not a prone position, for a pelvic examination.

Choice C is wrong because douching can alter the normal vaginal flora and pH, and increase the risk of infection.

Choice D is wrong because placing the client’s arms over their head can tighten the abdominal muscles and make the examination more difficult. The nurse should ask the client to place their arms at their sides or across their chest.

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A nurse is collecting data from a client prior to administration of verapamil. Which of the following findings indicates a need to withhold the medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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