saunders 2

Takes the client's blood pressure.

A client with angina pectoris who was given a first dose of newly prescribed nitroglycerin sublingual tablets complains of slight dizziness and headache. The nurse takes which action first?

Low blood glucose level

A client with diabetes mellitus who has been controlled with daily insulin has been placed on atenolol for the control of angina pectoris. Because of the effects of atenolol, the nurse determines that which is the most reliable indicator of hypoglycemia?

The child's pulse is less than 80 beats per minute.

A 1-year-old child has been prescribed digoxin to treat heart failure (HF). When would the nurse plan on withholding the prescribed dose of the medication?

Determine the client's ability to breathe effectively.

A client has taken his first dose of lisinopril about 2 hours ago and begins to develop fullness in his face and hoarseness. Which action would the nurse take first?

"I should decrease my intake of foods high in potassium such as bananas."

A client is being discharged following treatment for left-sided heart failure. The nurse is reinforcing teaching the client the purpose, actions, adverse effects, and use of digoxin and hydrochlorothiazide prescribed for daily use. Which statement by the client indicates a need for further teaching?

Protamine sulfate

A client is receiving heparin sodium by continuous intravenous (IV) infusion. The licensed practical nurse (LPN) is concerned that the client received a bolus of medication when the tubing was removed from the IV pump during a gown change. The LPN immediately notifies the registered nurse or primary health care provider and then checks to see whether which medication is available in the medication supply area in case it is prescribed?

Administer half of a medication tablet.

A client is scheduled to receive digoxin 0.125 mg by mouth. The licensed practical nurse (LPN) reads the medication label and notes that each tablet contains 0.25 mg. The LPN would perform which action?

Elevated potassium level Rationale:Eplerenone is a selective aldosterone receptor blocker. The medication is used for hypertension and heart failure and has one significant side effect, hyperkalemia. Therefore, options 1, 2, and 3 are incorrect.

A client taking an aldosterone antagonist known as eplerenone for hypertension asks about side effects of this medication. The nurse tells the client that which sign/symptom is a side effect?

Withhold the medication and call the PHCP if the pulse is less than 60 beats per minute.

A primary health care provider (PHCP) writes a prescription for digoxin, 0.25 mg daily. The nurse teaches the client about the medication and tells the client that it is important to do which?

Activated partial thromboplastin time (aPTT) of 55 seconds

Heparin sodium is prescribed for the client. Which laboratory result indicates that the heparin is prescribed at a therapeutic level?

If I see empty tab shells in my stool, I need to report it to my doctor." Client teaching about nifedipine includes changing position slowly to avoid orthostatic hypotension and avoiding grapefruit juice and alcohol. The client is not to discontinue nifedipine abruptly but gradually taper dosage. If empty tab shells appear in stools, it is not significant.

The client has been prescribed nifedipine. The nurse is instructing the client about nifedipine. Which client statement indicates a need for further teaching?

Prothrombin time (PT)4International normalized ratio (INR)

Warfarin sodium is prescribed for a client. The nurse expects that the primary health care provider will prescribe which laboratory tests to monitor for a therapeutic effect of the medication? Select all that apply.

The nurse is caring for a client who is taking metoprolol. The nurse measures the client's blood pressure (BP) and apical pulse immediately before administration. The client's BP is 122/78 mm Hg and the apical pulse is 58 beats per minute. Based on this data, which is the appropriate action?

Withhold the medication.

"The medication reduces my need for exercise."

The nurse is reinforcing instructions to a client with essential hypertension about medication therapy with irbesartan. Which client statement would indicate a need for further teaching?

Atenolol

The nurse is reviewing the health care provider's prescription sheet for the preoperative client, which states that the client must be on nothing by mouth (NPO) status after midnight. The nurse would clarify whether which medication would be given to the client rather than withheld?

Protamine sulfate3Intravenous tubing4Intravenous infusion controller5Intravenous insertion equipment

The nurse is asked to assist in preparing a heparin sodium infusion for a client with a diagnosis of thrombophlebitis. Which items would the nurse have available for this procedure? Select all that apply.

Blood pressure declines.

The nurse is assisting in monitoring a client who received hydralazine hydrochloride to treat autonomic dysreflexia. Which finding accurately indicates that the medication is effective?

Administer the dose of the medication as scheduled.

The nurse is caring for a client with chronic heart failure who is taking digoxin 0.125 mg daily. Before administering the medication, the nurse reviews the serum digoxin level that was drawn earlier in the day. The result is 1 ng/mL. Which action would the nurse take based on this laboratory result?

Withhold the medication.

The nurse is preparing to administer digoxin to an infant with heart failure (HF). Before administering the medication, the nurse double-checks the dose, counts the apical heart rate for 1 full minute, and obtains a rate of 88 beats per minute. Based on this finding, which is the appropriate nursing action?

Take pulse rate each day."4"Weigh at the same time each day."5"Palpitations may occur early in therapy."6"Be careful when rising from sitting to standing."

The nurse is reinforcing discharge teaching to a client who was given a prescription for nifedipine for blood pressure management. Which instructions would the nurse reinforce? Select all that apply.

"I can skip a dose once a week."

The nurse provides medication instructions to an older hypertensive client who is taking 20 mg of lisinopril orally daily. The nurse evaluates the need for further teaching when the client makes which statement?

"You are concerned about the side effects of your medication?"

A client is experiencing impotence after taking an antihypertensive medication. The client states, "I would sooner have a stroke than keep living with the side effects of this medication." The nurse would make which appropriate response to the client?

Heart rate

The nurse is preparing to administer digoxin, 0.125 mg orally, to a client with heart failure. Which vital sign is most important for the nurse to check before administering the medication?

Spinach Warfarin sodium is an anticoagulant. Anticoagulant medications act by antagonizing the action of vitamin K, which is needed for clotting. When a client is taking an anticoagulant, foods high in vitamin K often are omitted from the diet. Vitamin K-rich foods include green, leafy vegetables; fish; liver; coffee; and tea.

The nurse reinforces dietary instructions to a client who will be taking warfarin sodium. The nurse tells the client to avoid which food item?

Blood pressure of 198/110 mm Hg

A client is diagnosed with pulmonary embolism and is to be treated with thrombolytic therapy. The nurse would report which priority data collection finding to the registered nurse before initiating this therapy?