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?

Choice A rationale

While a family history of mental illness is important information to obtain when planning care for a client with major depression, it is not the most important information when the client is receiving a new prescription for duloxetine. Family history can provide insight into the client’s risk factors for depression, but it does not directly impact the safety or efficacy of duloxetine.

Choice B rationale

Weight change in the last month is not the most important information to obtain when planning care for a client with major depression who is receiving a new prescription for duloxetine. While significant weight changes can be a symptom of depression and should be monitored, they do not directly impact the safety or efficacy of duloxetine.

Choice C rationale

Liver function laboratory results are the most important information to obtain when planning care for a client with major depression who is receiving a new prescription for duloxetine.

Duloxetine is metabolized in the liver, and abnormal liver function can affect the metabolism and elimination of the drug, potentially leading to increased side effects or decreased effectiveness. Therefore, it is crucial to assess liver function before and during treatment with duloxetine.

Choice D rationale

While recent use of other antidepressants is important information to obtain when planning care for a client with major depression who is receiving a new prescription for duloxetine, it is not the most important information. This information can help prevent drug interactions and serotonin syndrome, a potentially life-threatening condition. However, liver function has a more direct impact on the safety and efficacy of duloxetine.

Choice A rationale

While maintaining a healthy lifestyle and diet is generally beneficial, consuming large amounts of leafy green vegetables, which are high in vitamin K, can interfere with the effectiveness of warfarin, a medication that works by inhibiting the action of vitamin K-dependent clotting factors. Therefore, praising the patient for her healthy lifestyle without addressing the potential interaction between her diet and medication could lead to suboptimal treatment outcomes.

Choice B rationale

This statement is misleading. While a healthy diet can contribute to overall health and well- being, the patient’s dietary choices, specifically her daily consumption of leafy green

vegetables, could actually decrease the effectiveness of warfarin. Warfarin’s ability to prevent blood clots is dependent on a consistent intake of vitamin K67.

Choice C rationale

This is the most appropriate response. The healthcare provider should be informed about the patient’s current diet because it could impact the effectiveness of warfarin. The provider may need to adjust the dose of warfarin or provide additional dietary guidance to ensure the medication works as intended.

Choice D rationale

While this might seem like a reasonable suggestion, it’s important to remember that dietary changes should be made in consultation with a healthcare provider or a dietitian. Substituting leafy green vegetables with other protein sources may not be necessary or appropriate depending on the patient’s overall diet, nutritional needs, and personal preferences.