Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The nurse prepares to administer a scheduled dose of labetalol by mouth to a client with hypertension. The client's vital signs are temperature 99° F (37.2° C), heart rate 48 beats/minute, respirations 16 breaths/minute, and blood pressure (B/P) 150/90 mm Hg. Which action should the nurse take?
A. Administer the dose and monitor the client's BP regularly.
Administering the dose of labetalol without further assessment may not be appropriate in this situation. The client's heart rate is 48 beats/minute, which is considered bradycardia (heart rate below the normal range of 60-100 beats/minute). Bradycardia can be a potential adverse effect of labetalol, a beta-blocker. Moreover, the client's blood pressure is elevated at 150/90 mm Hg, indicating that the hypertension is not well controlled. Administering the dose without addressing the bradycardia or elevated blood pressure could potentially exacerbate these issues.
B. Withhold the scheduled dose and notify the healthcare provider.
Withholding the scheduled dose of labetalol is the most appropriate action in this scenario. The client's heart rate of 48 beats/minute is considered bradycardia, which may be a side effect of labetalol or indicative of an underlying issue. Additionally, the client's blood pressure is elevated, indicating inadequate control of hypertension. Bradycardia can reduce cardiac output and may lead to further complications. Notifying the healthcare provider is essential to obtain further instructions and address the client's bradycardia and hypertension before administering the medication.
C. Apply a telemetry monitor before administering the dose.
While telemetry monitoring is appropriate for clients with certain cardiac conditions or when changes in heart rate need close observation, it may not be the most urgent action in this situation. The client's bradycardia and elevated blood pressure are concerning and require immediate attention. Telemetry monitoring may be considered later, but it does not address the immediate need to withhold the medication and seek guidance from the healthcare provider.
D. Assess for orthostatic hypotension before administering the dose.
Orthostatic hypotension refers to a drop in blood pressure when changing positions, such as from lying down to standing up. While orthostatic hypotension is a valid concern for clients taking antihypertensive medications, it is not the primary issue in this scenario. The client's heart rate is 48 beats/minute, indicating bradycardia, and the blood pressure is elevated at 150/90 mm Hg, suggesting uncontrolled hypertension. These are the main concerns that require immediate attention and further assessment before administering the labetalol dose.
This question is an excerpt from Nurse Dive's nursing test bank - Hesi Pharmacology Proctored Exam 2. Take the full exam now
Full Explanation
Choice A rationale: Administering the dose of labetalol without further assessment may not be appropriate in this situation. The client's heart rate is 48 beats/minute, which is considered bradycardia (heart rate below the normal range of 60-100 beats/minute). Bradycardia can be a potential adverse effect of labetalol, a beta-blocker. Moreover, the client's blood pressure is elevated at 150/90 mm Hg, indicating that the hypertension is not well controlled. Administering the dose without addressing the bradycardia or elevated blood pressure could potentially exacerbate these issues.
Choice B rationale: Withholding the scheduled dose of labetalol is the most appropriate action in this scenario. The client's heart rate of 48 beats/minute is considered bradycardia, which may be a side effect of labetalol or indicative of an underlying issue. Additionally, the client's blood
pressure is elevated, indicating inadequate control of hypertension. Bradycardia can reduce cardiac output and may lead to further complications. Notifying the healthcare provider is essential to obtain further instructions and address the client's bradycardia and hypertension before administering the medication.
Choice C rationale: While telemetry monitoring is appropriate for clients with certain cardiac conditions or when changes in heart rate need close observation, it may not be the most urgent action in this situation. The client's bradycardia and elevated blood pressure are concerning and require immediate attention. Telemetry monitoring may be considered later, but it does not address the immediate need to withhold the medication and seek guidance from the healthcare provider.
Choice D rationale: Orthostatic hypotension refers to a drop in blood pressure when changing positions, such as from lying down to standing up. While orthostatic hypotension is a valid concern for clients taking antihypertensive medications, it is not the primary issue in this scenario. The client's heart rate is 48 beats/minute, indicating bradycardia and the blood pressure is elevated at 150/90 mm Hg, suggesting uncontrolled hypertension. These are the main concerns that require immediate attention and further assessment before administering the labetalol dose.
Similar Questions
While assessing a client who takes acetaminophen for chronic pain, the nurse observes that the client's skin looks yellow in color. Which action should the nurse take in response to this finding?
A. Check the client's capillary glucose level.
Checking the capillary glucose level is not relevant to the observation of yellow skin color. Jaundice is related to liver function, not glucose levels.
B. Use a pulse oximeter to assess oxygen saturation.
Oxygen saturation measurement is not relevant to the observation of yellow skin color. It is used to assess the oxygen-carrying capacity of the blood, not liver function.
C. Report the finding to the healthcare provider.
Yellow discoloration of the skin (jaundice) can be indicative of liver dysfunction or damage. Since the client takes acetaminophen for chronic pain, which is metabolized in the liver, the nurse should be concerned about potential hepatotoxicity. Reporting the findings to the healthcare provider is essential for further evaluation and management.
D. Advise the client to reduce the medication dose.
Reducing the medication dose is not appropriate without further evaluation and guidance from the healthcare provider. Jaundice may indicate liver dysfunction, and altering the medication without professional assessment could be unsafe.
Full Explanation
Choice A rationale: Checking the capillary glucose level is not relevant to the observation of yellow skin color. Jaundice is related to liver function, not glucose levels.
Choice B rationale: Oxygen saturation measurement is not relevant to the observation of yellow skin color. It is used to assess the oxygen-carrying capacity of the blood, not liver function.
Choice C rationale: Yellow discoloration of the skin (jaundice) can be indicative of liver dysfunction or damage. Since the client takes acetaminophen for chronic pain, which is metabolized in the liver, the nurse should be concerned about potential hepatotoxicity. Reporting the findings to the healthcare provider is essential for further evaluation and management.
Choice D rationale: Reducing the medication dose is not appropriate without further evaluation and guidance from the healthcare provider. Jaundice may indicate liver dysfunction, and altering the medication without professional assessment could be unsafe.
The nurse is administering sodium polystyrene sulfonate to a client in acute kidney injury (AKI). Which laboratory finding indicates that the medication has been effective?
- Glucose [Reference Range: 74 to 106 mg/dL (4.1 to 5.9 mmol/L)]
- Hemoglobin (Hgb) [Reference Range:12-16 g/dL (120-160 g/L)]
- Potassium (K+) [Reference Range: 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]
- Ammonia [Reference Range: Adult: 10 to 80 Mcg/dL (6 to 47 Mcmol/dL)]
A. Serum ammonia level of 30 Mcg/dL (17.62 Mcmol /dL).
Serum ammonia levels are not relevant to the effectiveness of sodium polystyrene sulfonate in treating hyperkalemia.
B. Serum potassium level of 3.8 mEq/L (3.8 mmol/L).
Sodium polystyrene sulfonate is a medication used to treat hyperkalemia (high potassium levels). A serum potassium level of 3.8 mEq/L falls within the normal reference range (3.5 to 5.0 mEq/L), indicating that the medication has been effective in promoting the excretion of potassium and reducing hyperkalemia.
C. Serum glucose level of 120 mg/dL (6.7 mmol/L).
Serum glucose levels are not relevant to the effectiveness of sodium polystyrene sulfonate in treating hyperkalemia.
D. Hemoglobin level of 13.5 g/dL (135 g/L).
Hemoglobin levels are not relevant to the effectiveness of sodium polystyrene sulfonate in treating hyperkalemia.
Full Explanation
Choice A rationale: Serum ammonia levels are not relevant to the effectiveness of sodium polystyrene sulfonate in treating hyperkalemia.
Choice B rationale: Sodium polystyrene sulfonate is a medication used to treat hyperkalemia (high potassium levels). A serum potassium level of 3.8 mEq/L falls within the normal reference range (3.5 to 5.0 mEq/L), indicating that the medication has been effective in promoting the excretion of potassium and reducing hyperkalemia.
Choice C rationale: Serum glucose levels are not relevant to the effectiveness of sodium polystyrene sulfonate in treating hyperkalemia.
Choice D rationale: Hemoglobin levels are not relevant to the effectiveness of sodium polystyrene sulfonate in treating hyperkalemia.
The nurse is caring for a client who has been taking ibuprofen. Which finding is most important for the nurse report to the healthcare provider?
A. Hematemesis.
Hematemesis refers to the vomiting of blood and is a severe and potentially life-threatening adverse effect of ibuprofen. Ibuprofen belongs to the class of nonsteroidal anti-inflammatory drugs (NSAIDs), which can cause gastrointestinal bleeding and ulcerations. Hematemesis indicates significant gastrointestinal irritation or bleeding, and it requires immediate attention from the healthcare provider to assess and manage the client's condition.
B. Nausea.
Nausea is a common side effect of ibuprofen and other NSAIDs. While it is important to monitor and address any adverse effects experienced by the client, nausea alone is not as urgent or critical as hematemesis, which can indicate a more severe complication.
C. Insomnia.
Insomnia is not directly related to the use of ibuprofen. While sleep disturbances can occur as a side effect of some medications, it is not the most important finding to report to the healthcare provider in this context.
D. Dizziness.
Dizziness can be a side effect of ibuprofen, but it is not the most concerning finding in this situation. Hematemesis, which indicates potential gastrointestinal bleeding, is a more critical symptom that requires immediate attention and reporting to the healthcare provider.
Full Explanation
Choice A rationale: Hematemesis refers to the vomiting of blood and is a severe and potentially life-threatening adverse effect of ibuprofen. Ibuprofen belongs to the class of nonsteroidal anti-inflammatory drugs (NSAIDs), which can cause gastrointestinal bleeding and ulcerations.
Hematemesis indicates significant gastrointestinal irritation or bleeding, and it requires immediate attention from the healthcare provider to assess and manage the client's condition.
Choice B rationale: Nausea is a common side effect of ibuprofen and other NSAIDs. While it is important to monitor and address any adverse effects experienced by the client, nausea alone is not as urgent or critical as hematemesis, which can indicate a more severe complication.
Choice C rationale: Insomnia is not directly related to the use of ibuprofen. While sleep disturbances can occur as a side effect of some medications, it is not the most important finding to report to the healthcare provider in this context.
Choice D rationale: Dizziness can be a side effect of ibuprofen, but it is not the most concerning finding in this situation. Hematemesis, which indicates potential gastrointestinal bleeding, is a more critical symptom that requires immediate attention and reporting to the healthcare provider.