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The nurse prepares to administer a scheduled dose of labetalol PO to a client with hypertension. The client's vital signs are a temperature of 99° F (37.2° C), a heart rate of 48 beats/minute, respirations of 16 breaths/minute, and a blood pressure of 150/90 mm Hg. Which action should the nurse take?
- A. Apply a telemetry monitor before administering the dose.
- B. Assess for orthostatic hypotension before administering the dose.
- C. Administer the dose and monitor the client's blood pressure regularly.
- D. Withhold the scheduled dose and notify the healthcare provider.
Correct Answer: D
Rationale: A heart rate of 48 beats/minute indicates bradycardia, a concern with labetalol (a beta-blocker). Withholding the dose and notifying the provider is appropriate to prevent worsening bradycardia.
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The nurse is caring for a client with atrial fibrillation who receives a prescription for warfarin. The international normalized ratio (INR) is 2.8. Which action should the nurse take?
- A. Obtain another blood sample.
- B. Give the next scheduled dose.
- C. Monitor for signs of bleeding.
- D. Notify the healthcare provider.
Correct Answer: C
Rationale: An INR of 2.8 is within the therapeutic range for atrial fibrillation, but monitoring for bleeding is critical as a routine precaution. Repeating the sample, giving the dose, or notifying the provider are less immediate.
Prior to administering an oral dose of methylprednisolone, the nurse determines the client's serum total calcium level is 5.5 mg/dL (1.375 mmol/L). What action is most important for the nurse to take?
- A. Administer the medication with a glass of milk.
- B. Begin tapering the drug dose per protocol.
- C. Notify the healthcare provider of the finding.
- D. Teach the client about foods high in calcium.
Correct Answer: C
Rationale: A calcium level of 5.5 mg/dL is critically low, requiring immediate provider notification for evaluation. Milk administration, tapering, or dietary teaching are not immediate priorities.
Before administering a laxative to a bedfast client, it is most important for the nurse to perform which assessment?
- A. Assess the client's strength in moving and turning in the bed.
- B. Observe the skin integrity of the client's rectal and sacral areas.
- C. Evaluate the client's ability to recognize the urge to defecate.
- D. Determine the frequency and consistency of bowel movements.
Correct Answer: D
Rationale: Assessing bowel movement frequency and consistency is critical to determine the need for a laxative and monitor its effectiveness. Strength, skin integrity, and urge recognition are less directly related to laxative administration.
A client with multiple sclerosis starts a new prescription, baclofen, to control muscle spasticity. Three days later, the client calls the clinic nurse and reports feeling fatigued and dizzy. Which instruction should the nurse provide?
- A. Avoid hazardous activities until symptoms subside.
- B. Stop taking the medication immediately.
- C. Increase intake of fluids and high-protein foods.
- D. Obtain transportation to the emergency department.
Correct Answer: A
Rationale: Fatigue and dizziness are common baclofen side effects, so avoiding hazardous activities is appropriate. Stopping abruptly, increasing fluids/protein, or seeking emergency care are not warranted without further assessment.
Furosemide is prescribed for a client with a history of heart failure (HF). Which foods should the nurse encourage this client to eat?
- A. Cheese, milk, and yogurt.
- B. Liver, beef, and chicken.
- C. Bananas, oranges, and peaches.
- D. Pasta, cereal, and bread.
Correct Answer: C
Rationale: Furosemide causes potassium loss, so potassium-rich foods like bananas, oranges, and peaches should be encouraged. Dairy, meats, and carbohydrates do not address potassium needs.