The nurse is planning the home care of a client who is receiving a mydriatic medication. Which environment is best for this client?

A cool, humidified air.

A quiet, restful environment.

A dimly lit room.

A warm room temperature.

Answer and Explanation

The Correct Answer is C

Choice A reason: A cool, humidified air is not relevant for this client, as it does not affect the eyes or vision. A cool, humidified air may be beneficial for clients with respiratory conditions, such as asthma or bronchitis.

Choice B reason: A quiet, restful environment is not specific for this client, as it does not address the effects of mydriatic medication on the eyes or vision. A quiet, restful environment may be helpful for clients with stress, anxiety, or insomnia.

Choice C reason: A dimly lit room is the best environment for this client, as it reduces the glare and discomfort caused by mydriatic medication. Mydriatic medication is a type of eye drop that dilates the pupils and prevents them from constricting in response to light. This can improve the examination of the retina and optic nerve, but it also makes the eyes more sensitive to light and reduces the ability to focus on near objects.

Choice D reason: A warm room temperature is not necessary for this client, as it does not affect the eyes or vision. A warm room temperature may be comfortable for clients with cold intolerance, such as hypothyroidism or Raynaud's phenomenon.

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Correct Answer is C

Explanation

Choice A reason: Replacing leafy vegetables with a protein source is not necessary or advisable for a vegetarian client who takes warfarin. Leafy vegetables are rich in vitamin K, which can interfere with warfarin's anticoagulant effect, but they also provide other nutrients and benefits for health. Protein sources such as nuts or beans may also contain vitamin K or other substances that can affect warfarin's action.

Choice B reason: Commending the client for her healthy lifestyle and encouraging her to continue her current diet habits is not appropriate or safe for a vegetarian client who takes warfarin. Leafy vegetables can alter warfarin's anticoagulant effect and increase the risk of bleeding or clotting complications if not monitored closely by the healthcare provider.

Choice C reason: Advising the client that the healthcare provider needs to be made aware of her current diet is the best response for a vegetarian client who takes warfarin. Leafy vegetables can affect warfarin's anticoagulant effect by increasing vitamin K levels in the body, which counteracts warfarin's action. The healthcare provider can adjust the warfarin dose accordingly and monitor the client's international normalized ratio (INR), which is a measure of blood clotting time.

Choice D reason: Confirming that her diet choices will help the medication be more effective in preventing blood clots is incorrect and misleading for a vegetarian client who takes warfarin. Leafy vegetables can decrease warfarin's anticoagulant effect by increasing vitamin K levels in the body, which enhances blood clotting. This can reduce the effectiveness of warfarin and increase the risk of thromboembolic events, such as stroke or pulmonary embolism.

A. Assess for orthostatic hypotension before administering the dose. B. Administer the dose and monitor the client's B/P regularly. C. Apply a telemetry monitor before administering the dose. D. Withhold the scheduled dose and notify the healthcare provider.

Correct Answer is D

Explanation

Choice A reason: Assessing for orthostatic hypotension before administering the dose is not necessary, as labetalol does not cause orthostatic hypotension. Orthostatic hypotension is a condition where the blood pressure drops significantly when changing positions from lying to sitting or standing. Labetalol is a beta-blocker that lowers blood pressure by reducing the heart rate and cardiac output.

Choice B reason: Administering the dose and monitoring the client's B/P regularly is not appropriate, as labetalol may cause further bradycardia (slow heart rate) in this client. The client's heart rate is already below normal (48 beats/minute), which may indicate that labetalol is overdosed or contraindicated. Bradycardia can lead to decreased perfusion, dizziness, fatigue, and fainting.

Choice C reason: Applying a telemetry monitor before administering the dose is not sufficient, as labetalol may cause serious cardiac arrhythmias (irregular heart rhythms) in this client. The client's heart rate is already below normal (48 beats/minute), which may indicate that labetalol is affecting the electrical conduction system of the heart. Arrhythmias can cause palpitations, chest pain, shortness of breath, and cardiac arrest.

Choice D reason: Withholding the scheduled dose and notifying the healthcare provider is the best action for the nurse to take in this situation. The client's heart rate is already below normal (48 beats/minute), which may indicate that labetalol is causing adverse effects or interactions with other medications. The healthcare provider should be informed of the client's vital signs and medication history, and decide whether to adjust or discontinue labetalol.

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The nurse is planning the home care of a client who is receiving a mydriatic medication. Which environment is best for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A female client who is a vegetarian has a new prescription for warfarin. The client states she eats leafy green vegetables every day. How should the nurse respond?

Correct Answer is C

Explanation

The nurse prepares to administer a scheduled dose of labetalol by mouth to a client with hypertension. The client's vital signs are temperature 99°F (37.22°C), heart rate 48 beats/minute, respirations 16 breaths/minute, and blood pressure (B/P) 150/90 mm Hg. Which action should the nurse take?

Correct Answer is D

Explanation

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