A nurse is caring for a client due for their dose of carvedilol (Coreg). The nurse completes vital signs prior to administration of the medication. Which vital sign would be an indication to hold the dose scheduled and notify the healthcare provider?
Blood pressure 102/76
Temperature of 100.3 F
Respiratory rate 10
Heart rate of 49
The Correct Answer is D
A) Blood pressure 102/76: While this blood pressure reading is on the lower side, it does not typically warrant withholding carvedilol unless the client exhibits symptoms of hypotension, such as dizziness or fainting. Carvedilol is an antihypertensive, but the reading itself is not critically low enough to necessitate holding the medication.
B) Temperature of 100.3 F: A mild fever at this temperature does not directly relate to carvedilol administration. It may indicate an underlying infection or inflammation, but it is not a contraindication for administering the medication. Monitoring the client’s temperature is important, but it does not require notifying the healthcare provider in this context.
C) Respiratory rate 10: A respiratory rate of 10 breaths per minute indicates bradypnea, which can be concerning. However, it is not the primary reason to withhold carvedilol unless the client shows significant respiratory distress. Monitoring is essential, but the decision to withhold the medication would depend on the overall clinical picture.
D) Heart rate of 49: A heart rate of 49 bpm is considered bradycardia and is a significant concern when administering carvedilol, a beta-blocker that can further decrease heart rate. It is essential to hold the medication and notify the healthcare provider, as this bradycardia could lead to potential adverse effects or complications. Monitoring the client's heart rate is crucial in managing their medication safely.
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Correct Answer is C
Explanation
A) Ambulating soon after surgery: Early ambulation is encouraged for postoperative clients to promote circulation and reduce the risk of venous thromboembolism (VTE). Mobilizing helps prevent stasis of blood in the veins, making this an appropriate action rather than an unsafe one.
B) Flexing her ankles: Ankle flexion exercises can help improve venous return and circulation in the lower extremities. This action is generally recommended to prevent VTE, making it a safe and beneficial practice for postoperative clients.
C) Massaging her legs: Massaging the legs is considered unsafe for a client at risk for VTE. This action can dislodge a thrombus (blood clot) if one is present, leading to potential complications such as pulmonary embolism. Therefore, the nurse should instruct the client to avoid leg massages.
D) Elevating her feet: Elevating the feet is a recommended practice to promote venous return and reduce swelling in postoperative clients. This action can help prevent VTE and is generally considered safe and beneficial.
Correct Answer is A
Explanation
A. "For confirmed diagnosis of hypertension, the BP readings should be higher than normal on 2 or more separate occasions.": This statement accurately reflects the criteria for diagnosing hypertension. According to guidelines, a diagnosis is typically confirmed when blood pressure readings consistently exceed normal levels (usually defined as 130/80 mm Hg) on two or more separate visits.
B. "For confirmed diagnosis of hypertension, BP readings should be lower than normal on only one occasion.": This statement is incorrect. A single low reading does not confirm a diagnosis of hypertension. In fact, it contradicts the concept of hypertension, which involves consistently high readings.
C. "For confirmed diagnosis of hypertension, BP readings should be higher than normal on more than three separate occasions.": This statement is misleading. While multiple readings are often taken, the threshold for diagnosis is two or more elevated readings, not three.
D. "For confirmed diagnosis of hypertension, the BP readings should be higher than normal on only one occasion.": This statement is inaccurate, as a single elevated reading is not sufficient for diagnosis. Consistent elevations over multiple occasions are necessary for a confirmed diagnosis.