The healthcare provider prescribes two doses of an antihypertensive medication for a client. Before administering the second dose, the nurse obtains a blood pressure measurement of 80/50 mm Hg. Which action should the nurse take?

Position the client in a lateral lying position.

Document the blood pressure and monitor the client.

Encourage an increase in oral fluid intake.

Hold the medication and notify the healthcare provider.

Answer and Explanation

The Correct Answer is D

A. Positioning the client in a lateral lying position might help with comfort but does not address the immediate concern of the low blood pressure.
B. Documenting the blood pressure and monitoring the client is important, but it does not address the need to prevent potential adverse effects from administering the medication at such a low blood pressure.
C. Encouraging an increase in oral fluid intake may be helpful in managing blood pressure, but the immediate priority should be to address the potential effects of the medication on the low blood pressure.
D. Holding the medication and notifying the healthcare provider is the appropriate action because administering the medication with a blood pressure of 80/50 mm Hg could worsen hypotension and lead to further complications. The healthcare provider should be informed to reassess the medication plan.

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Correct Answer is B

Explanation

A. Hypothyroidism is not directly related to obstructive sleep apnea. While sleep apnea can have various systemic effects, hypothyroidism is not a common complication associated with it.
B. Obstructive sleep apnea is strongly associated with an increased risk of hypertension. The repeated episodes of oxygen desaturation and arousal during sleep can contribute to increased blood pressure and cardiovascular strain.
C. Peptic ulcer disease is not a known complication of obstructive sleep apnea. It is generally associated with factors like H. pylori infection, NSAID use, and stress rather than sleep apnea.
D. Fibromyalgia is a chronic pain syndrome and is not typically associated with obstructive sleep apnea. Sleep apnea can exacerbate fatigue and sleep disturbances but does not directly cause fibromyalgia.

A. Apply a warm compress to the sacral area. B. Wash the area with soap and water. C. Reassess and turn the client in 30 minutes. D. Massage the reddened area with lotion.

Correct Answer is C

Explanation

A. Applying a warm compress does not address the prevention of pressure ulcers and could potentially exacerbate skin issues. The primary focus should be on preventing further pressure.
B. Washing the area with soap and water does not effectively address the issue of pressure ulcer risk or the need for repositioning to alleviate pressure.
C. Reassessing and turning the client every 30 minutes helps prevent the development of pressure ulcers by relieving pressure on vulnerable areas, which is crucial for maintaining skin integrity.
D. Massaging the reddened area can cause further damage and is not recommended. Proper repositioning and pressure relief are the appropriate interventions.

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The healthcare provider prescribes two doses of an antihypertensive medication for a client. Before administering the second dose, the nurse obtains a blood pressure measurement of 80/50 mm Hg. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with obstructive sleep apnea. The nurse should recognize the client is at greater risk for the development of which complication?

Correct Answer is B

Explanation

When turning a male client who has been lying on his back for 2 hours, the nurse notes that the skin over his sacrum is very white. The client is repositioned and when the nurse reassesses the sacrum 2 hours later, the area is bright red. Which intervention should the nurse implement?

Correct Answer is C

Explanation

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