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. Dizziness during perineal cleansing is not a common concern and should not be included as a standard part of perineal care instructions.
B. For male clients, the foreskin should be retracted gently if it is retractable to clean the area underneath. However, if the foreskin is not retractable or if retraction causes discomfort, it should not be forced. This instruction is crucial for proper hygiene and prevention of infection.
C. While an erection can occur, it is not a standard concern to highlight during perineal care education. The focus should be on proper technique and hygiene.
D. Shaving the pubic area is not necessary for perineal care and can potentially cause irritation or increase the risk of infection. Proper hygiene practices are more important than hair removal.

A. Temperature. B. Blood pressure. C. Heart rate. D. Respiratory rate.

Correct Answer is D

Explanation

A. Temperature is important but does not directly address the immediate concern of cyanosis, which suggests possible issues with oxygenation.
B. Blood pressure is also important, but in the context of cyanosis, assessing the respiratory status is more directly related to identifying the cause of decreased oxygenation.
C. Heart rate is crucial for assessing circulatory status, but cyanosis often indicates a problem with oxygenation, making it less immediately relevant compared to respiratory assessment.
D. Respiratory rate should be assessed first as cyanosis can indicate impaired oxygenation, which is often due to respiratory issues. Evaluating the respiratory rate helps determine if there is a problem with breathing or gas exchange that needs immediate attention.

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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

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