The practical nurse (PN) is preparing to administer a maintenance dose of an antihypertensive medication to an adult client and notes that the client’s blood pressure is 120/72 mm Hg. Which action should the PN take?
Confer with the charge nurse about the need to administer the medication
Advise the client to call the PN for symptoms of increasing blood pressure
Withhold the medication and recheck the client’s blood pressure in one hour
Administer the scheduled dose of the antihypertensive medication
The Correct Answer is D
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Range of motion assesses muscle relaxant effectiveness, as these drugs, like cyclobenzaprine, reduce muscle spasms by acting on the central nervous system, relieving pain and improving mobility. Increased leg movement indicates reduced spasm and pain, directly reflecting the drug’s therapeutic action.
Choice B reason: Capillary refill evaluates perfusion, not muscle relaxation. Muscle relaxants target spasms, not vascular status. While pain may indirectly affect circulation, capillary refill does not measure the drug’s primary effect on muscle function, making this choice irrelevant.
Choice C reason: Dependent edema reflects fluid status, not muscle relaxant efficacy. These drugs reduce muscle tension, not swelling. Edema is unrelated to leg pain from spasms, and muscle relaxants do not affect fluid dynamics, making this choice inappropriate for assessment.
Choice D reason: Skin temperature may indicate inflammation or circulation but is not specific to muscle relaxant effects. These drugs alleviate spasms, improving mobility, not temperature. Range of motion directly measures spasm relief, making this choice less relevant for evaluating the medication’s impact.
Correct Answer is C
Explanation
Choice A reason: Suggesting a snack after administering an incorrect insulin dose risks hypoglycemia, as 2 extra units can excessively lower blood glucose. Insulin dosing must match the glucose level per the sliding scale to prevent adverse effects, making this choice unsafe and reactive.
Choice B reason: Repeating the glucose level is unnecessary if the recorded level is reliable. The error lies in the drawn dose, not the glucose measurement. Correcting the dose to match the recorded glucose is more direct, as insulin dosing relies on accurate glucose data.
Choice C reason: Reducing the insulin dose by 2 units corrects the error, aligning with the sliding scale for the recorded glucose level. Excess insulin can cause hypoglycemia, affecting brain and organ function. This action ensures safe administration, preventing potentially severe metabolic consequences.
Choice D reason: Recording the discrepancy does not correct the dosing error and risks administering an unsafe dose. Documentation is secondary to ensuring the correct insulin amount is given, as 2 extra units could lead to hypoglycemia, requiring immediate correction, not just notation.
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