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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: Observing the client’s ability to open the pill box ensures accessibility but does not address nitroglycerin’s stability. Nitroglycerin degrades when exposed to air, light, or plastic, reducing potency. The original container is critical for maintaining efficacy, making this choice secondary.

Choice B reason: Nitroglycerin must be stored in its original amber glass container to protect it from light, air, and moisture, which degrade its potency. Plastic pill boxes allow exposure, reducing effectiveness for angina relief. Explaining this ensures the client maintains the drug’s therapeutic integrity.

Choice C reason: Reminding the client to refresh nitroglycerin every 30 days is relevant due to its short shelf life, but the priority is proper storage. Without the original container, even fresh pills lose potency, making this choice less critical than ensuring correct storage conditions.

Choice D reason: Labeling the pill box improves usability but does not address nitroglycerin’s stability. Plastic containers expose the drug to air and light, reducing efficacy. Proper storage in the original container is more critical to ensure the drug remains effective for emergency use.

A. Pupils equal and reactive to light B. Heart rate 106 beats/minute C. Respiratory rate 22 breaths/minute D. Urine output 40 mL/hour

Correct Answer is C

Explanation

Choice A reason: Pupils equal and reactive to light assess neurological status, not bronchodilator effectiveness. Bronchodilators, like albuterol, relax airway smooth muscles, improving breathing in emphysema. Pupil response is unrelated to respiratory function, making this choice irrelevant for evaluating the drug’s impact.

Choice B reason: Heart rate of 106 beats/minute may reflect a bronchodilator side effect, as beta-agonists stimulate cardiac beta receptors, causing tachycardia. However, it does not measure effectiveness, which is assessed by improved airway function, like respiratory rate, making this choice incorrect.

Choice C reason: Respiratory rate of 22 breaths/minute indicates bronchodilator effectiveness, as these drugs dilate airways, reducing work of breathing in emphysema. A normalized rate suggests improved airflow and oxygenation, directly reflecting the drug’s therapeutic action on bronchial smooth muscle relaxation.

Choice D reason: Urine output of 40 mL/hour monitors renal function, not bronchodilator efficacy. Bronchodilators target airway dilation, not fluid balance. This finding is unrelated to emphysema treatment or the drug’s respiratory effects, making it irrelevant for assessing medication effectiveness.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Sublingual nitroglycerin is prescribed PRN for an older adult female client with a history of chest pain. The client shows the practical nurse (PN) a plastic pill box that she purchased so the medication can always be readily available in her purse. Which action should the PN take?

Correct Answer is B

Explanation

A client with emphysema who is receiving a bronchodilator reports to the practical nurse (PN) feelings of jitters and dry mouth. Which finding should the PN record as a measure of the medication’s effectiveness?

Correct Answer is C

Explanation

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