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 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.

A. Pasta, cereal, and bread. B. Cheese, milk, and yogurt. C. Liver, beef, and chicken. D. Bananas, oranges, and peaches.

Correct Answer is D

Explanation

Choice A Reason:

Pasta, cereal, and bread are not particularly rich in potassium, which is important for clients taking furosemide. Furosemide is a loop diuretic that can cause the body to lose potassium, so it is essential to consume potassium-rich foods to maintain normal levels. These foods are more carbohydrate-based and do not provide the necessary potassium.

Choice B Reason:

Cheese, milk, and yogurt are good sources of calcium and protein but are not the best sources of potassium. While dairy products do contain some potassium, they are not as rich in potassium as fruits like bananas, oranges, and peaches. Additionally, clients with heart failure may need to monitor their intake of dairy products due to their sodium content.

Choice C Reason:

Liver, beef, and chicken are excellent sources of protein and iron but are not particularly high in potassium. While these foods are beneficial for overall nutrition, they do not address the specific need for increased potassium intake in clients taking furosemide.

Choice D Reason:

Bananas, oranges, and peaches are rich in potassium, which is crucial for clients taking furosemide. Furosemide can lead to hypokalemia (low potassium levels), and consuming potassium-rich foods helps to counteract this effect. Potassium is vital for maintaining normal heart function and muscle contractions. Including these fruits in the diet can help prevent the adverse effects of low potassium levels, such as muscle weakness, cramps, and arrhythmias.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with heart failure (HF) develops hyperaldosteronism and spironolactone is prescribed. Which instruction should the nurse include in the client’s plan of care?

Correct Answer is D

Explanation

Furosemide is prescribed for a client with a history of heart failure (HF). Which foods should the nurse encourage this client to eat?

Correct Answer is D

Explanation

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