A nurse is preparing to administer a client's antihypertensive medication. When using clinical judgment, which of the following findings indicates the nurse should collect further data from the client before administering medication?

The client reports having trouble sleeping the previous night.

The client reports dizziness when ambulating to the bathroom.

The client has a urine output of 400 mL for the past 8 hr

The client ate 60% of their breakfast.

Answer and Explanation

The Correct Answer is B

A. Trouble sleeping the previous night may not be directly related to the decision to withhold antihypertensive medication.
B. Dizziness when ambulating could indicate hypotension, which can be exacerbated by antihypertensive medication. The nurse should collect further data to ensure the patient's blood pressure is safe for medication administration.
C. Urine output is important to monitor but does not directly indicate a need to withhold antihypertensive medication unless associated with other symptoms.
D. Eating 60% of breakfast does not indicate a need to collect further data before administering antihypertensive medication.

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Correct Answer is C

Explanation

Intramuscular administration provides relatively quick absorption but is slower than intravenous.
B. Enteral (oral) administration has the slowest absorption rate due to the process of digestion and first-pass metabolism in the liver.
C. Intravenous administration delivers the medication directly into the bloodstream, resulting in the fastest absorption and onset of action.
D. Topical administration is typically used for localized treatment and has a slower absorption rate compared to intravenous.

A. Leave the medication at the client's bedside. B. Come back in a few minutes to administer the medication in order to allow the client to finish with therapy. C. Prepare the medication in the medication room to quickly administer to the client once finished with therapy. D. Document the medication was given because the client will take it when they return to their room.

Correct Answer is B

Explanation

Leaving medication at the client's bedside is unsafe as it can lead to medication errors, missed doses, or accidental ingestion.
B. Coming back in a few minutes to administer the medication respects the client’s therapy schedule and ensures the nurse can directly observe the client taking the medication, ensuring proper administration and adherence.
C. Preparing the medication in the medication room ahead of time can be efficient but doesn’t address the need to personally administer the medication and confirm the client takes it.
D. Documenting the medication was given without actually administering it is unethical and against best practices as it assumes the client will take the medication without verification.

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A nurse is preparing to administer a client's antihypertensive medication. When using clinical judgment, which of the following findings indicates the nurse should collect further data from the client before administering medication?

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