The nurse is preparing to administer a scheduled dose of labetalol orally to a client with hypertension.
The client’s vital signs are temperature 99° F (37.2 C), heart rate 48 beats/minute, respirations 16 breaths/minute, and blood pressure (BP) 150/90 mm Hg. What action should the nurse take?

Withhold the scheduled dose and notify the healthcare provider.

Administer the dose and monitor the client’s BP regularly.

Assess for orthostatic hypotension before administering the dose.

Apply a telemetry monitor before administering the dose.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Labetalol is a non-selective beta-blocker used to treat hypertension. The goal of labetalol administration is to reduce the blood pressure to 140/90 mmHg, and the diastolic BP must not fall below 90 mmHg. However, in this scenario, the client’s heart rate is 48 beats/minute, which is lower than the normal range (60-100 beats/minute). Administering labetalol, which can further decrease heart rate, could lead to bradycardia, a condition that can cause fainting, fatigue, or chest discomfort. Therefore, the nurse should withhold the scheduled dose and notify the healthcare provider.

Choice B rationale

While it is important to monitor the client’s BP regularly when administering labetalol, given the client’s low heart rate, administering the dose could potentially exacerbate the client’s bradycardia. Therefore, this choice is not the most appropriate action for the nurse to take in this situation.

Choice C rationale

Assessing for orthostatic hypotension before administering the dose is an important consideration when administering medications that can lower blood pressure. However, in this case, the client’s low heart rate is a more immediate concern. Therefore, this choice is not the most appropriate action for the nurse to take in this situation.

Choice D rationale

Applying a telemetry monitor could help in monitoring the client’s heart rate and rhythm. However, given the client’s current heart rate, the priority should be to withhold the medication and inform the healthcare provider.

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Correct Answer is C

Explanation

Choice A rationale

Excessive bruising is not a typical side effect of atorvastatin, and it is not linked to increased CK levels. Excessive bruising can be caused by bleeding disorders, anticoagulant therapy, or trauma.

Choice B rationale

Peripheral edema is not a common side effect of atorvastatin, and it is not related to increased CK levels. CK is an enzyme that is released when muscle tissue is damaged. Peripheral edema is more likely to be caused by heart failure, kidney disease, or venous insufficiency.

Choice C rationale

Muscle tenderness is a sign of myopathy, which is a rare but serious adverse effect of atorvastatin. Myopathy is a condition where muscle fibers are damaged and inflamed, leading to muscle weakness and pain. Increased CK levels indicate muscle injury and can be a marker of myopathy. The nurse should monitor the client for muscle symptoms and report them to the prescriber.

Choice D rationale

Nausea and vomiting are common gastrointestinal side effects of atorvastatin, but they are not associated with increased CK levels. Nausea and vomiting can be managed by taking the medication with food or reducing the dose.

A. Replace salt with a salt substitute. B. Cover your skin before going outside. C. Limit intake of high-potassium foods. D. Monitor skin for excessive bruising.

Correct Answer is C

Explanation

Choice A rationale

While reducing salt intake is generally beneficial for clients with heart failure, replacing salt with a salt substitute is not recommended for clients taking spironolactone. Many salt

substitutes contain potassium, and spironolactone can cause high potassium levels in the blood.

Choice B rationale

Covering the skin before going outside is a general recommendation for sun protection, but it is not specifically related to the use of spironolactone.

Choice C rationale

Spironolactone is a potassium-sparing diuretic, which means it can cause the body to retain potassium. Therefore, clients taking this medication should be advised to limit their intake of high-potassium foods to prevent hyperkalemia, a potentially serious condition characterized by high levels of potassium in the blood.

Choice D rationale

While it is always important to monitor for signs of bruising, this is not the most critical instruction for a client taking spironolactone. The risk of hyperkalemia is a more immediate concern.

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The nurse is preparing to administer a scheduled dose of labetalol orally to a client with hypertension.The client’s vital signs are temperature 99° F (37.2 C), heart rate 48 beats/minute, respirations 16 breaths/minute, and blood pressure (BP) 150/90 mm Hg. What action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client taking atorvastatin has an increased serum creatine phosphokinase (CK) level. What should the nurse assess the client for?

Correct Answer is C

Explanation

A client with heart failure (HF) develops hyperaldosteronism and spironolactone is prescribed. Which instruction should the nurse include in this client’s plan of care?

Correct Answer is C

Explanation

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The nurse is preparing to administer a scheduled dose of labetalol orally to a client with hypertension.
The client’s vital signs are temperature 99° F (37.2 C), heart rate 48 beats/minute, respirations 16 breaths/minute, and blood pressure (BP) 150/90 mm Hg. What action should the nurse take?