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 D

Explanation

Choice A rationale

While reducing the dosage of a medication might be appropriate in some cases, it’s not the best initial action when a patient’s skin appears yellow. Yellowing of the skin, or jaundice, can be a sign of liver damage, which can be a serious side effect of acetaminophen. The healthcare provider should be notified before any changes are made to the medication regimen.

Choice B rationale

Checking the patient’s capillary glucose level would not be the most appropriate response to the observation of yellow skin. While it’s important to monitor glucose levels in patients with certain conditions, such as diabetes, it would not provide information about potential liver damage, the likely cause of the patient’s yellow skin.

Choice C rationale

Using a pulse oximeter to assess the patient’s oxygen saturation would not provide information about the cause of the patient’s yellow skin. While it’s an important assessment in many situations, it would not help in identifying potential liver damage from acetaminophen use.

Choice D rationale

This is the most appropriate action. Yellowing of the skin can be a sign of liver damage, a potential side effect of acetaminophen. The healthcare provider should be notified of this observation as soon as possible for further evaluation and management.

A. Explain that the client needs to allow for sleep time of at least two hours. B. Advise the client to take the medication with the noon meal. C. Encourage the client to wait until bedtime to take the medication. D. Remind the client to drink plenty of fluids when taking the medication.

Correct Answer is C

Explanation

Choice A rationale

Explaining that the client needs to allow for sleep time of at least two hours after taking zolpidem is not the best action. While it’s true that zolpidem should be taken right before going to sleep, the client’s plan to take a short afternoon nap may not provide enough time for the effects of the medication to wear off, which could lead to drowsiness and potential safety issues.

Choice B rationale

Advising the client to take the medication with the noon meal is not the best action. Zolpidem should be taken on an empty stomach right before going to sleep. Taking it with food or right after a meal may decrease its effectiveness.

Choice C rationale

Encouraging the client to wait until bedtime to take the medication is the best action. Zolpidem is a sedative-hypnotic medication used to treat insomnia. It works quickly to put you to sleep and should be taken right before going to bed. Taking it during the day could lead to drowsiness and potential safety issues.

Choice D rationale

Reminding the client to drink plenty of fluids when taking the medication is not the best action. While staying hydrated is generally good advice, it’s not specifically related to the use of zolpidem. The key instruction for zolpidem is to take it right before going to bed.

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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?

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Naxlex Comprehensive Predictor Exams

While evaluating a patient who has been taking acetaminophen for chronic pain, the nurse notices that the patient’s skin appears yellow.What action should the nurse take in response to this observation?

Correct Answer is D

Explanation

A client has a new prescription for zolpidem, a hypnotic.The client tells the home health nurse that he plans to take a dose of the medication during the day because he is exhausted and needs to take a short afternoon nap prior to an evening activity in his home.Which action should the nurse take?

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?