Administer a scheduled dose of labetalol PO to a client with hypertension. The client’s temperature is 99°F (37.2°C), a heart rate of 48 beats per minute, respirations of 16 breaths per minute, and a blood pressure of 150/90 mm Hg. Which action should the nurse take?
Withhold the scheduled dose and notify the healthcare provider.
Administer the dose and monitor the client’s blood pressure regularly.
Assess for orthostatic hypotension before administering the dose.
Apply a telemetry monitor before administering the dose.
The Correct Answer is A
Choice A reason: Withholding the scheduled dose and notifying the healthcare provider is the correct action because the client’s heart rate is significantly low at 48 beats per minute. Labetalol, a beta-blocker, can further reduce the heart rate, potentially leading to bradycardia or other cardiac complications. It is crucial to inform the healthcare provider to reassess the medication regimen and ensure the client’s safety.
Choice B reason: Administering the dose and monitoring the client’s blood pressure regularly is not advisable in this scenario. Although monitoring blood pressure is important, the primary concern here is the client’s low heart rate. Administering labetalol could exacerbate bradycardia, leading to severe complications.
Choice C reason: Assessing for orthostatic hypotension before administering the dose is a good practice but not the most critical action in this situation. The client’s low heart rate poses a more immediate risk than orthostatic hypotension. Therefore, withholding the medication and notifying the healthcare provider is a higher priority.
Choice D reason: Applying a telemetry monitor before administering the dose is useful for continuous cardiac monitoring, but it does not address the immediate concern of the client’s low heart rate. The priority should be to withhold the medication and consult the healthcare provider to prevent potential bradycardia.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Spironolactone is a potassium-sparing diuretic often prescribed for heart failure. While monitoring for side effects is important, excessive bruising is not a common side effect of spironolactone. Bruising might be more relevant for patients on anticoagulants or those with clotting disorders.
Choice B Reason:
Replacing salt with a salt substitute is not advisable for patients on spironolactone. Many salt substitutes contain potassium chloride, which can lead to hyperkalemia (high potassium levels) when combined with spironolactone. Hyperkalemia can cause serious cardiac issues, including arrhythmias.
Choice C Reason:
Covering the skin before going outside is not specifically related to the use of spironolactone. This advice might be more relevant for medications that cause photosensitivity, such as certain antibiotics or diuretics like hydrochlorothiazide, but not spironolactone.
Choice D Reason:
Limiting the intake of foods high in potassium is crucial for patients taking spironolactone. Spironolactone can increase potassium levels in the blood, and consuming high-potassium foods (like bananas, oranges, and potatoes) can exacerbate this effect, leading to hyperkalemia. Hyperkalemia can be dangerous and cause symptoms such as muscle weakness, fatigue, and cardiac arrhythmias.
Correct Answer is D
Explanation
Choice A reason: While it is true that breastfeeding is not recommended while taking isotretinoin due to the potential for adverse effects on the infant, this is not the most critical information for a client planning to become pregnant. The primary concern is the teratogenic effects of isotretinoin, which can cause severe birth defects.
Choice B reason: Advising the client not to take multiple vitamins that contain vitamin A while on isotretinoin is important because excessive vitamin A can increase the risk of toxicity. However, this is not the most crucial information for someone planning to become pregnant. The teratogenic risks of isotretinoin are a higher priority.
Choice C reason: Obtaining baseline liver function results is necessary during isotretinoin therapy due to the potential for hepatotoxicity. Regular monitoring helps ensure the liver is functioning properly. However, this information is secondary to the need to avoid pregnancy while on isotretinoin due to its severe teratogenic effects.
Choice D reason: Discontinuing isotretinoin one month before attempting to conceive is the most important information. Isotretinoin is highly teratogenic and can cause serious birth defects. It is crucial to stop the medication well before conception to ensure it is completely cleared from the body, reducing the risk of harm to the fetus.
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