The nurse is preparing to administer a client's scheduled antihypertensive medication (lisinopril). The client's vital signs are:
Blood pressure: 88/56 mmHg
Heart rate: 62 bpm
Respiratory rate: 18/min
Oxygen saturation: 98% n room air
Encourage the client to drink fluids and then give the medication.
Hold the dose and notify the healthcare provider
Give half the dose and recheck the blood pressure in 30 minutes.
Document the finding and give the drug as usual
Hold the dose and notify the healthcare provider
The Correct Answer is B
A. Encourage the client to drink fluids and then give the medication: While increasing fluid intake can help raise blood pressure if the cause is dehydration, it does not justify giving an antihypertensive to a hypotensive patient. Administering lisinopril will further lower the pressure regardless of fluid status. The priority is to avoid exacerbating the existing hypotension.
B. Hold the dose and notify the healthcare provider: A blood pressure of 88/56 is significantly below the normal therapeutic range and indicates that the patient cannot tolerate further antihypertensive therapy. Giving the lisinopril could lead to profound hypotension, syncope, or decreased organ perfusion. The nurse must withhold the drug and seek medical guidance for dose adjustment.
C. Give half the dose and recheck the blood pressure in 30 minutes: Nurses are not authorized to alter the prescribed dose of a medication or provide a partial dose without a specific physician order. Even a half-dose of an ACE inhibitor could be dangerous for a client whose pressure is already below 90 mmHg systolic. Clinical judgment requires stopping the medication entirely until the patient is stable.
D. Document the finding and give the drug as usual: Giving the drug as usual despite a blood pressure of 88/56 is a medication error that ignores critical assessment data. This action directly endangers the patient and violates basic safety protocols for administering cardiovascular medications. Documentation of the vital signs must be followed by an appropriate clinical action, which is withholding the dose.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. smoking cessation.: Thromboangiitis obliterans is an inflammatory vascular disease strongly linked to tobacco use. The primary pathophysiological trigger is an autoimmune response to nicotine that leads to segmental vasculitis and digital ischemia. Complete abstinence from all tobacco products is the only effective way to halt the progression of the disease and prevent gangrene or amputation.
B. reduction of alcohol intake.: While excessive ethanol consumption is detrimental to overall cardiovascular health, it is not the primary causative agent for Buerger's disease. Alcohol does not induce the specific segmental inflammation of small and medium-sized arteries seen in this pathology. Smoking cessation remains a far more critical lifestyle modification for these patients.
C. avoiding cold remedies.: Some over-the-counter cold medications contain sympathomimetics that can cause peripheral vasoconstriction. While patients with Raynaud's phenomenon should be cautious, these drugs do not drive the inflammatory process of Buerger's disease. The focus of nursing education must prioritize the elimination of tobacco rather than secondary pharmacological triggers.
D. weight reduction.: Obesity is a significant risk factor for atherosclerosis, but Buerger's disease is a non-atherosclerotic inflammatory condition. While maintaining a healthy body mass index is beneficial for systemic health, it does not stop the specific vasculitis associated with this condition. Tobacco use is the specific modifiable factor that determines the clinical trajectory.
Correct Answer is C
Explanation
A. Cardiac catheterization: This is an invasive procedure where a catheter is threaded through the femoral or radial artery to inject dye and visualize the coronary anatomy. It is performed while the patient is stationary on a procedure table, not while exercising on a treadmill. It is the gold standard for diagnosing blockages but is not a "stress test."
B. Electrocardiogram: A standard 12-lead ECG records the electrical activity of the heart while the patient is at rest. While it can show signs of previous infarction or current ischemia, it does not involve physical exertion. It is a baseline diagnostic tool rather than a functional assessment of the heart under stress.
C. Stress test: An exercise stress test involves monitoring the patient's heart rate, blood pressure, and ECG while they walk on a treadmill at increasing levels of difficulty. This test is designed to uncover myocardial ischemia that may only be present when the heart's oxygen demand is elevated. It is a key functional evaluation for patients with suspected angina.
D. Echocardiogram: An echocardiogram uses ultrasound waves to visualize the structures and motion of the heart valves and chambers. While it can be performed after exercise in a "stress echo," the primary test focused on exercising on a treadmill for ischemia detection is the stress test. A standard echo is typically a resting imaging study.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.