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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale:

While a tuberculin syringe can be used for insulin administration, it’s not necessary when mixing NPH and regular insulin. Insulin syringes are typically used for this purpose.

Choice B rationale:

Injecting air into each vial before withdrawing insulin helps equalize pressure and makes it easier to draw up the insulin. This should be done before withdrawing any insulin.

Choice C rationale:

Withdrawing NPH insulin first contradicts the standard practice of drawing up insulins. The usual recommendation is to draw up short-acting (regular) insulin before intermediate-acting (NPH) insulin.

Choice D rationale:

Shaking the regular insulin vial is unnecessary and could potentially create bubbles, making it harder to draw up the correct dose of insulin.

A. Dissolve the medication in 30 mL of water. B. Maintain the client in the supine position during medication administration. C. Add the medication to the enteral feeding formula. D. Flush the tube with 5 mL of water after administering the medication.

Correct Answer is A

Explanation

Choice A rationale:

Dissolving the medication in 30 mL of water is the correct action. This ensures that the medication is in a suitable form for administration via an NG tube and helps prevent the tube from becoming blocked.

Choice B rationale:

Maintaining the client in the supine position during medication administration is not recommended. This position increases the risk of aspiration. Instead, the client should be in an upright position during medication administration and for at least 30 minutes afterward.

Choice C rationale:

Adding the medication to the enteral feeding formula is not recommended. This can alter the effectiveness of the medication and can also clog the feeding tube.

Choice D rationale:

Flushing the tube with 5 mL of water after administering the medication is not enough. The tube should be flushed with at least 15-30 mL of water before and after medication administration to ensure that the entire dose has been administered and to prevent clogging of the tube.

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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?

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Naxlex Comprehensive Predictor Exams

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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?