A nurse is reviewing data for a client who receives clonidine daily.
Which of the following findings indicates the nurse should withhold the next dose?
Urine output 600 mL in 8 hr.
Blood pressure 88/50 mm Hg.
Heart rate 110/min.
Blood glucose 70 mg/dL.
The Correct Answer is B
Choice A rationale:
A urine output of 600 mL in 8 hours is within the normal range. The average urine output for adults is about 1 to 2 liters per day.
Choice B rationale:
Clonidine is an antihypertensive medication. If the client’s blood pressure is already low (88/50 mm Hg), administering clonidine could further lower the blood pressure and cause hypotension.
Choice C rationale:
A heart rate of 110/min is slightly high, but it’s not a direct indication to withhold clonidine. Clonidine can actually help lower an elevated heart rate by reducing the levels of certain chemicals in your blood.
Choice D rationale:
A blood glucose level of 70 mg/dL is at the lower end of the normal range (70-100 mg/dL) However, clonidine does not directly affect blood glucose levels, so this would not be a reason to withhold the medication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Asking for a home phone number is not an effective method for identifying a patient. Phone numbers can be easily forgotten or mixed up, especially in a hospital setting where a patient may be under stress or experiencing health issues.
Choice B rationale:
Room numbers can change if the patient is moved, and other patients may have previously occupied the same room. Therefore, room numbers are not reliable identifiers.
Choice C rationale:
Asking the patient to confirm their own name is one of the most direct and reliable ways to verify their identity. This method respects patient autonomy and privacy while ensuring accurate identification.
Choice D rationale:
Age alone is not a reliable identifier because it does not distinguish between different patients of the same age.
Correct Answer is D
Explanation
Choice A rationale:
Consulting a pharmaceutical sales representative is not the best option. While they are knowledgeable about the medications they promote, their primary role is to market their company’s products, and they may not have comprehensive information about other medications.
Choice B rationale:
While a nursing team member can be a valuable resource, they may not have the specific knowledge about the medication in question. It’s also important to remember that medication information can change frequently, and relying on another person’s knowledge may lead to errors.
Choice C rationale:
The client’s family can provide useful information about how the client has been taking the medication at home, but they are unlikely to have detailed pharmacological knowledge about the medication.
Choice D rationale:
A nursing drug guide is a reliable and up-to-date resource that provides comprehensive information about medications, including indications, contraindications, dosages, potential side effects, and interactions. Therefore, when unfamiliar with a medication, the nurse should consult a nursing drug guide.
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