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.

Answer and Explanation

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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Correct Answer is C

Explanation

Choice A reason:

Teaching the client about foods high in calcium is important, but it is not the most immediate action required. A serum calcium level of 5.5 mg/dL is significantly below the normal range (8.5-10.2 mg/dL) and indicates severe hypocalcemia. While dietary education is beneficial for long-term management, the nurse must first address the acute issue by notifying the healthcare provider.

Choice B reason:

Beginning to taper the drug dose per protocol is not appropriate without consulting the healthcare provider. Methylprednisolone, a corticosteroid, can cause decreased calcium absorption and increased calcium excretion. However, any changes to the medication regimen should be directed by the healthcare provider, especially in the context of severe hypocalcemia.

Choice C reason:

Notifying the healthcare provider of the finding is the most critical action. Severe hypocalcemia can lead to serious complications such as cardiac arrhythmias, muscle spasms, and seizures. Immediate medical intervention is necessary to correct the calcium imbalance and prevent potential life-threatening conditions.

Choice D reason:

Administering the medication with a glass of milk is not sufficient to address the severe hypocalcemia. While milk contains calcium, the amount is not enough to correct a serum calcium level as low as 5.5 mg/dL. The nurse must prioritize notifying the healthcare provider to ensure appropriate treatment is initiated.

Word count: 500 words.

A. Explain to the family how to inject this medication for severe hypoglycemia. B. Teach the client self-injection skills for daily subcutaneous administration. C. Demonstrate how to select the dose based on before-meal blood sugar readings. D. Provide information on increasing medication dosage if ketoacidosis occurs.

Correct Answer is B

Explanation

Choice A reason: Insulin glargine is a long-acting insulin used to manage blood glucose levels in patients with diabetes. It is not typically used for the acute management of severe hypoglycemia. Instead, fast-acting glucose sources or glucagon injections are recommended for severe hypoglycemia. Therefore, teaching the family how to inject insulin glargine for severe hypoglycemia is not appropriate.

Choice B reason: Teaching the client self-injection skills for daily subcutaneous administration is crucial. Insulin glargine is administered once daily to provide a steady level of insulin throughout the day and night. Proper self-injection technique ensures that the medication is delivered correctly and effectively, which is essential for managing blood glucose levels in type 2 diabetes.

Choice C reason: While it is important for patients to monitor their blood sugar levels, insulin glargine dosing is typically fixed and not adjusted based on before-meal blood sugar readings. Instead, adjustments to the dose are made based on overall blood glucose trends and A1C levels, under the guidance of a healthcare provider.

Choice D reason: Increasing the dosage of insulin glargine in response to ketoacidosis is not appropriate. Diabetic ketoacidosis (DKA) is a medical emergency that requires immediate treatment with rapid-acting insulin, fluids, and electrolytes. Patients should be instructed to seek emergency medical care if they experience symptoms of DKA.

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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?

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Naxlex Comprehensive Predictor Exams

Prior to administering an oral dose of methylprednisolone, the nurse determines the client’s serum total calcium level is 5.5 mg/dL (1.375 mmol/L). What action is most important for the nurse to take?

Correct Answer is C

Explanation

The nurse is planning discharge teaching for a client with type 2 diabetes mellitus who has a new prescription for insulin glargine. Which action should the nurse plan to include in the discharge teaching?

Correct Answer is B

Explanation

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?

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