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.
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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Related Questions
Correct Answer is C
Explanation
A. Hydrochlorothiazide should not be taken at bedtime as it is a diuretic and can cause nocturia.
B. Increased swelling of the ankles is not an expected effect of hydrochlorothiazide and could indicate worsening heart failure or other issues.
C. Taking weight at the same time every day helps monitor fluid status and the effectiveness of the diuretic.
D. Limiting fluid intake in the morning is not recommended, as adequate hydration is important while taking diuretics.
Correct Answer is C
Explanation
A. Asking patients their names can help, but it is not the most reliable method, especially if patients are confused or unable to communicate.
B. Asking another nurse about their identities can introduce errors and is not a standard practice for patient identification.
C. Checking the patients' ID bands and patient information ensures accurate identification using multiple identifiers (e.g., name, birth date, medical record number), adhering to best practices for patient safety.
D. Verifying names with family members can be helpful but is not as reliable or standardized as checking ID bands and patient information.
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