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 C

Explanation

A. Developing a plan for increasing activity and mobility is important but is not the immediate priority during the prodromal stage of an infection.
B. Discharge planning and teaching are relevant for patient management but not the priority during the early stages of infection.
C. Implementing precautions to prevent disease transmission is crucial during the prodromal stage, as this is when the infection may be most contagious. Preventing the spread of infection is the top priority.
D. Offering fluids and ice chips helps with comfort and hydration but does not address the prevention of disease transmission.

A. Hospital pharmacist. B. Healthcare provider. C. Medication reference guide. D. Nursing unit charge nurse.

Correct Answer is B

Explanation

A. The hospital pharmacist can provide valuable information about medication dosages and potential discrepancies, but the primary source for clarification about the prescribed treatment plan is the healthcare provider who issued the prescription.
B. The healthcare provider should be contacted first to clarify the dosage discrepancy. The provider can confirm whether the dosage is correct or if there was an error in the prescription. This ensures that any potential issues are addressed by the person responsible for the treatment plan.
C. A medication reference guide is useful for checking normal dosages, but it does not clarify if a specific prescription is appropriate for the client’s condition. The provider’s confirmation is necessary for resolving discrepancies.
D. The nursing unit charge nurse may be consulted for additional guidance but is not the primary resource for verifying or resolving prescription dosages.

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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

During the prodromal stage of an infection, which is the priority nursing intervention?

Correct Answer is C

Explanation

Correct Answer is B

Explanation

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