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The nurse is preparing to administer a scheduled dose of labetalol orally 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 (BP) 150/90 mm Hg. What action should the nurse take?
- A. Withhold the scheduled dose and notify the healthcare provider.
- B. Administer the dose and monitor the client’s BP regularly.
- C. Assess for orthostatic hypotension before administering the dose.
- D. Apply a telemetry monitor before administering the dose.
Correct Answer: A
Rationale: Labetalol, a beta-blocker, can worsen bradycardia (heart rate 48 bpm). Withholding the dose and notifying the provider (A) is safest. Administering (B) risks exacerbating bradycardia. Orthostatic hypotension assessment (C) and telemetry (D) are secondary.
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A client is receiving intravenous vancomycin, and the nurse plans to draw blood for a peak and trough to determine the serum level of the drug. Which collection times would provide the best determination of these levels?
- A. One hour after completion of the IV dose and one hour before the next administration of the medication.
- B. Two hours after completion of the IV dose and two hours before the next administration of the medication.
- C. Thirty minutes into the administration of the IV dose and 30 minutes before the next administration of the medication.
- D. Immediately after completion of the IV dose and 30 minutes before the next administration of the medication.
Correct Answer: A
Rationale: Vancomycin peak levels are drawn 1 hour post-infusion, and trough levels 1 hour pre-dose (A) for accurate therapeutic monitoring. Two-hour intervals (B) miss peak/trough. Mid-infusion (C) is too early for peak. Immediate post-dose (D) underestimates peak.
A patient is receiving a secondary infusion of azithromycin 500 mg in 500 mL of normal saline (NS) to be infused over 2 hours. The intravenous (IV) administration set delivers 10 gtt/mL. How many gtt/min should the nurse regulate the infusion?
Correct Answer: 42
Rationale: Infusion rate: 500 mL / 2 hr = 250 mL/hr. Drops per minute: (250 mL/hr × 10 gtt/mL) / 60 min = 41.67, rounded to 42 gtt/min. This ensures accurate delivery of azithromycin.
A patient with osteoporosis is administered risedronate at 0700 and requests a glass of milk to take with the medication. What should the nurse’s response be?
- A. Advise the patient to only consume water with the medication.
- B. Delay the medication until the patient’s breakfast tray arrives.
- C. Consult with a pharmacist about administering the dose one hour post-meal.
- D. Assign an unlicensed assistive personnel to bring the patient a glass of low-fat milk.
Correct Answer: A
Rationale: This question is identical to Question 1. Risedronate requires plain water on an empty stomach (A) to ensure absorption. Milk (D) reduces efficacy. Delaying for breakfast (B) or post-meal dosing (C) violates guidelines. Note: Duplicate question; consider removing.
A client with benign prostatic hyperplasia has been prescribed tamsulosin. What should the nurse do to monitor for an adverse reaction?
- A. Monitor the client’s blood pressure.
- B. Assess the client’s urine output.
- C. Perform a bladder scan.
- D. Obtain the client’s daily weights.
Correct Answer: A
Rationale: Tamsulosin, an alpha-blocker, can cause hypotension and dizziness (A), requiring blood pressure monitoring. Urine output (B) and bladder scans (C) assess BPH, not adverse effects. Daily weights (D) monitor fluid status, not tamsulosin risks.
A nurse is caring for a client diagnosed with stage 4 cancer who has a prescription for a subcutaneous morphine sulfate patch for pain. The client is short of breath and difficult to arouse. During a head-to-toe assessment, the nurse finds four patches on the client’s body. What should be the nurse’s first action?
- A. Administer a narcotic reversal drug.
- B. Apply an oxygen face mask.
- C. Remove the morphine patches.
- D. Monitor the client’s blood pressure.
Correct Answer: C
Rationale: Four morphine patches suggest overdose, causing respiratory depression and sedation. Removing the patches (C) stops further absorption. Naloxone (A) or oxygen (B) may follow, but removal is first. Blood pressure monitoring (D) is secondary.