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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is B
Explanation
A. Within the expected reference range: While a blood pressure of 130/82 mm Hg is close to normal, it is not considered fully within the expected reference range. The normal range is typically defined as less than 120/80 mm Hg.
B. Elevated: The reading of 130/82 mm Hg falls into the "elevated" category, which is defined as systolic blood pressure between 120-129 mm Hg and diastolic pressure less than 80 mm Hg. This indicates that while the client is not hypertensive, they are at increased risk for developing hypertension in the future.
C. Stage 2 hypertension: This category is defined by a systolic reading of 140 mm Hg or higher, or a diastolic reading of 90 mm Hg or higher. The client’s reading does not meet these criteria, so this option is not applicable.
D. Stage 1 hypertension: Stage 1 hypertension is characterized by systolic readings between 130-139 mm Hg and diastolic readings between 80-89 mm Hg. Although the systolic reading is in the Stage 1 range, the diastolic reading of 82 mm Hg places the overall reading in the "elevated" category, rather than Stage 1 hypertension.
Correct Answer is ["B","E"]
Explanation
A) Provide discharge instructions for a client who has a new skin graft: This task should not be delegated to an assistive personnel (AP) as it requires clinical judgment and knowledge about the specific care needs associated with a new skin graft. Discharge instructions must be provided by a qualified nurse.
B) Weigh a client who is on fluid restriction: This task can be delegated to an AP. Weighing a client is a straightforward procedure that does not require nursing judgment and is within the scope of practice for an AP.
C) Check a blood product with another nurse prior to administration: This task must be performed by a licensed nurse to ensure patient safety and compliance with protocols. Checking blood products requires knowledge of the client's specific needs and potential reactions.
D) Perform an admission assessment on a client: Admission assessments require nursing expertise and critical thinking. This task cannot be delegated to an AP, as it involves evaluating the client's condition and creating a care plan based on the assessment findings.
E) Ambulate an older adult client who has hypertension: This task can be delegated to an AP, provided the client is stable and there are no other complications. Assisting with ambulation is within the scope of practice for an AP, and it can help promote mobility and independence for the client.