The practical nurse (PN) is administering the 0900 medications to a client who was admitted during the night. Which client statement indicates that the PN should further assess the prescription?

Choice A reason: Conferring with the charge nurse is unnecessary, as a blood pressure of 120/72 mm Hg is within normal range for a client on maintenance antihypertensive therapy. Maintenance doses prevent hypertension recurrence, and this reading does not indicate a need to alter the schedule.

Choice B reason: Advising the client to report rising blood pressure symptoms is general education, not an action addressing the current situation. The blood pressure is normal, and the maintenance dose is indicated to sustain control, making this choice irrelevant for immediate action.

Choice C reason: Withholding the medication and rechecking in an hour risks blood pressure spikes, as maintenance therapy prevents hypertension. A normal reading of 120/72 mm Hg indicates effective control, and stopping the dose could destabilize the client’s condition, making this choice inappropriate.

Choice D reason: Administering the scheduled antihypertensive dose is correct, as 120/72 mm Hg indicates effective blood pressure control. Maintenance therapy sustains normotension by regulating vascular tone or fluid balance, preventing hypertensive episodes, ensuring cardiovascular stability, and aligning with the prescription’s intent.

Choice A reason: Iodine allergy is irrelevant to golimumab, a tumor necrosis factor (TNF) inhibitor, as it is not iodine-based. Allergic reactions to biologics are possible but unrelated to iodine sensitivity, making this choice unnecessary for ensuring safe administration of the medication.

Choice B reason: Flu vaccination status is relevant for general health but not critical before golimumab administration. While immunosuppression increases infection risk, tuberculosis screening is more urgent, as TNF inhibitors can reactivate latent TB, posing a severe health threat.

Choice C reason: A recent tuberculosis test is essential, as golimumab suppresses TNF, increasing the risk of reactivating latent TB into active disease. Screening with a tuberculin test or interferon-gamma assay prevents potentially fatal infections, making this the most critical information before starting therapy.

Choice D reason: Oral contraceptive use is unrelated to golimumab’s safety or efficacy. While some drugs interact with contraceptives, golimumab does not, and psoriasis treatment does not involve reproductive considerations, making this choice irrelevant for pre-administration assessment.