The nurse knows that the adverse effects of a nonselective beta blocker are likely to be the most immediately life-threatening in which patient?

Choice A rationale

Administering a medication when there is a strong possibility the patient has already received it could lead to an overdose. The automated dispensing machine's record indicates removal of the dose, and the patient's statement, despite her confusion, suggests she might have taken it. The nurse's primary responsibility is patient safety and preventing medication errors, which this action would violate.

Choice B rationale

This is the safest course of action. The medication was removed from the machine, and the patient states she thinks she took it. The night shift nurse's failure to sign the MAR is a documentation error, but the potential for a double dose is a serious safety concern. The nurse should hold the dose and investigate further before administering anything to prevent an iatrogenic event.

Choice C rationale

Notifying the provider for a new order is an unnecessary and premature step. The issue is not that the medication is unavailable or the order is incorrect. The immediate concern is whether the patient has already received the dose. Holding the medication and verifying the administration is the correct first step, and the provider would not be contacted unless there was a clinical reason to do so, such as if the blood glucose became dangerously high.

Choice D rationale

Giving the insulin and then monitoring the patient is dangerous. Administering an additional dose of insulin could cause a severe hypoglycemic event, especially in a confused patient. The blood glucose of 142 mg/dL is not critically high, so there is no immediate need for the insulin, and the risk of a medication error outweighs any perceived benefit of administering the medication immediately.

Choice A rationale

This response is incorrect because a persistent, dry cough in a patient on an ACE inhibitor is a significant adverse effect requiring medical evaluation. It is not something that will simply resolve on its own. The cough is thought to be caused by the accumulation of bradykinin and substance P in the lungs, which occurs due to the inhibition of the ACE enzyme, which normally degrades these peptides. This is a common but bothersome side effect that warrants a change in medication.

Choice B rationale

While increasing fluid intake is generally beneficial for health, it is not an effective treatment for a medication-induced cough. The cough is a direct result of the pharmacological action of the ACE inhibitor on the kinin-kallikrein system, not dehydration. The patient's cough is a physiological response to the medication, and fluids will not mitigate the underlying biochemical process causing the bradykinin accumulation and airway irritation.

Choice C rationale

This is the most appropriate action. The dry cough is a classic and common side effect of ACE inhibitors, affecting up to 20% of patients. It is caused by the accumulation of bradykinin, a vasodilator peptide, due to the inhibition of angiotensin-converting enzyme. This persistent and often irritating symptom may necessitate a change to an alternative class of antihypertensive drugs, such as an angiotensin II receptor blocker (ARB), which does not affect bradykinin levels.

Choice D rationale

Discontinuing the medication without consulting the healthcare provider is unsafe and outside the scope of nursing practice. Abruptly stopping an antihypertensive drug can lead to a dangerous rebound effect, causing a sudden and severe increase in blood pressure, known as a hypertensive crisis. The decision to change or stop a medication must always be made by the prescribing healthcare provider after evaluating the benefits versus the side effects.