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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is A
Explanation
This is outside of the expected reference range for a 2-week-old infant, which is 30 to 60 breaths per minute. A respiratory rate higher than 60 breaths per minute can indicate respiratory distress or infection.
Choice B is wrong because BP 64/42 mm Hg is within the normal range for a 2-week-old infant, which is 65 to 85/45 to 55 mm Hg.
Choice C is wrong because Axillary temperature 36.6° C (97.9° F) is within the normal range for a 2-week-old infant, which is 36.5 to 37.5° C (97.7 to 99.5° F).
Choice D is wrong because Apical heart rate 124/min is within the normal range for a 2-week-old infant, which is 110 to 160 beats per minute.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today