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 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.

A. Withhold the next dose and contact the healthcare provider B. Obtain a cooling blanket from the hospital central supply department C. Take the client to a quiet area and provide reassurance D. Administer a PRN prescription for benzodiazepine and acetaminophen

Correct Answer is A

Explanation

Choice A reason: Restlessness, tachycardia, fever, and hypertension suggest serotonin syndrome, a life-threatening paroxetine side effect due to excessive serotonin. Withholding the dose and contacting the provider prevents further serotonin accumulation, allowing urgent assessment and intervention to stabilize the client’s neurological and cardiovascular status.

Choice B reason: A cooling blanket addresses fever but is not the first action for serotonin syndrome. Withholding paroxetine and consulting the provider are critical to stop the syndrome’s progression, as fever is a symptom, not the cause, making this choice secondary to halting the drug.

Choice C reason: Taking the client to a quiet area may reduce stimulation but does not address serotonin syndrome’s physiological cause. Paroxetine’s serotonin excess drives symptoms, requiring drug cessation and medical intervention, not just reassurance, as this condition can rapidly worsen, making this choice inadequate.

Choice D reason: Administering benzodiazepine and acetaminophen is premature without provider guidance, as serotonin syndrome requires specific treatments, like cyproheptadine. Paroxetine must be stopped first, and the provider consulted to confirm diagnosis and manage symptoms, making this choice unsafe and reactive.

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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

The practical nurse (PN) is checking the insulin dose drawn up by another PN and notes that the amount of insulin is 2 units more than the amount indicated for the glucose level written on the client’s medication record. Which action should the PN take?

Correct Answer is C

Explanation

The practical nurse (PN) is caring for a client receiving a prescription for paroxetine who suddenly exhibits restlessness, tachycardia, fever, and elevated blood pressure. Which action should the PN implement first?

Correct Answer is A

Explanation

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