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. Administer a PRN dose of an antianxiety drug. B. Obtain orthostatic blood pressure readings. C. Notify the healthcare provider. D. Collect a capillary glucose level.

Correct Answer is C

Explanation

Choice A reason:

Administering a PRN dose of an antianxiety drug might seem like a reasonable action if the tremors are related to anxiety. However, without a clear indication that anxiety is the cause of the tremors, this action could mask the underlying issue and delay appropriate treatment. It is essential to identify the root cause of the tremors before administering any medication.

Choice B reason:

Obtaining orthostatic blood pressure readings is a useful assessment for determining if the client has orthostatic hypotension, which can cause dizziness and fainting. However, this action is not directly related to the complaint of hand tremors. While it is a good practice to monitor vital signs, it does not address the immediate concern of tremors caused by pregabalin.

Choice C reason:

Notifying the healthcare provider is the most appropriate action. Tremors can be a side effect of pregabalin12. The healthcare provider needs to be informed to evaluate the severity of the side effect and decide whether to adjust the medication dosage or switch to an alternative treatment. This ensures that the client receives the most appropriate care and avoids potential complications.

Choice D reason:

Collecting a capillary glucose level is important for clients with diabetes or those at risk of hypoglycemia or hyperglycemia. However, there is no indication in the scenario that the client has diabetes or that blood glucose levels are related to the tremors. Therefore, this action is not directly relevant to the client’s current complaint.

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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

A client who is receiving pregabalin for fibromyalgia complains of tremors in the hands. Which action should the nurse implement?

Correct Answer is C

Explanation

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