The nurse knows that a medication has the side effect of orthostatic hypotension. Which assessment should the nurse make before administering the medication?

Apical heart rate.

Pulse pressure.

Level of consciousness.

Blood pressure.

Answer and Explanation

The Correct Answer is D

Choice A reason: The apical heart rate is important for other assessments but does not directly assess for orthostatic hypotension.

Choice B reason: Pulse pressure is not specifically related to orthostatic hypotension assessment.

Choice C reason: Level of consciousness can be affected by orthostatic hypotension but is not the primary assessment.

Choice D reason: Blood pressure should be measured in both lying and standing positions to assess for orthostatic hypotension.

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Correct Answer is C

Explanation

Choice A reason: Ear pain and fever are not specific symptoms of mononucleosis and may indicate other infections such as otitis media.

Choice B reason: Elevated WBC (white blood cell) count and sedimentation rate can be seen in many infections and inflammatory conditions, but they are not specifically diagnostic of mononucleosis.

Choice C reason: Mononucleosis, often caused by the Epstein-Barr virus (EBV), typically presents with a positive EBV test and malaise (general feeling of discomfort or illness). Other common symptoms include fever, sore throat, swollen lymph nodes, and fatigue.

Choice D reason: Increased BUN (blood urea nitrogen) and serum creatinine levels are indicators of kidney function and are not typically associated with mononucleosis.

A. Sodium intake with meals and snacks affects the blood pressure. B. Hypotension leading to sudden shock can develop at any time. C. Elevated blood pressure must be anticipated and identified quickly. D. Blood pressure fluctuations mean that the condition has become chronic.

Correct Answer is C

Explanation

Choice A reason: While sodium intake can affect blood pressure, this response does not address the importance of frequent blood pressure monitoring in the context of acute glomerulonephritis.

Choice B reason: Hypotension leading to sudden shock is not a common complication of acute glomerulonephritis; instead, hypertension is more likely due to fluid retention and kidney impairment.

Choice C reason: Elevated blood pressure is a significant concern in acute glomerulonephritis due to fluid retention and decreased kidney function. Early identification and management of hypertension are crucial to prevent complications such as seizures or heart failure.

Choice D reason: Blood pressure fluctuations do not necessarily indicate that the condition has become chronic. Frequent monitoring is necessary to manage acute symptoms and prevent complications.

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The nurse knows that a medication has the side effect of orthostatic hypotension. Which assessment should the nurse make before administering the medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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