,Enalapril maleate is prescribed for a hospitalized client. Which assessment does the nurse
perform as a priority before administering the medication?
Checking the client's blood pressure
Checking the client's peripheral pulses
Checking the most recent potassium level
Checking the client's intake-and-output record for the last 24 hours - ANSWER
Checking the client's blood pressure
B
Rationale: Enalapril maleate is an angiotensin-converting enzyme (ACE) inhibitor used
LU
to treat hypertension. One common side effect is postural hypotension. Therefore the
nurse would check the client's blood pressure immediately before administering each
dose. Checking the client's peripheral pulses, the results of the most recent potassium
level, and the intake and output for the previous 24 hours are not specifically associated
YC
with this mediation.
A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse
provides instructions to the client about the test. Which statement by the client indicates a
D
need for further instruction?
TU
"The test will take about 30 minutes."
"I need to fast for 8 hours before the test."
"I need to drink citrate of magnesia the night before the test and give myself a Fleet
enema on the morning of the test."
ES
"I need to take a laxative after the test is completed, because the liquid that I'll have to
drink for the test can be constipating." - ANSWER "I need to drink citrate of
magnesia the night before the test and give myself a Fleet enema on the morning of the
test."
C
Rationale: No special preparation is necessary before a GI series, except that NPO
A
(nothing by mouth) status must be maintained for 8 hours before the test. An upper GI
series involves visualization of the esophagus, duodenum, and upper jejunum by means
of the use of a contrast medium. It involves swallowing a contrast medium (usually
barium), which is administered in a flavored milkshake. Films are taken at intervals
during the test, which takes about 30 minutes. After an upper GI series, the client is
prescribed a laxative to hasten elimination of the barium. Barium that remains in the
colon may become hard and difficult to expel, leading to fecal impaction.
,A nurse on the evening shift checks a primary health care provider's prescriptions and
notes that the dose of a prescribed medication is higher than the normal dose. The nurse
calls the primary health care provider's answering service and is told that the primary
health care provider is off for the night and will be available in the morning. What should
the nurse do next?
Call the nursing supervisor
B
Ask the answering service to contact the on-call primary health care provider
Withhold the medication until the primary health care provider can be reached in the
LU
morning
Administer the medication but consult the primary health care provider when he becomes
available - ANSWER Ask the answering service to contact the on-call primary health
care provider
YC
Rationale: The nurse has a duty to protect the client from harm. A nurse who believes
that a primary health care provider's prescription may be in error is responsible for
clarifying the prescription before carrying it out. Therefore the nurse would not
D
administer the medication; instead, the nurse would withhold the medication until the
dose can be clarified. The nurse would not wait until the next morning to obtain
TU
clarification. It is premature to call the nursing supervisor.
An emergency department (ED) nurse is monitoring a client with suspected acute
myocardial infarction (MI) who is awaiting transfer to the coronary intensive care unit.
ES
The nurse notes the sudden onset of premature ventricular contractions (PVCs) on the
monitor, checks the client's carotid pulse, and determines that the PVCs are not perfusing.
What is the nurse's most appropriate action?
C
Document the findings
Ask the ED primary health care provider to check the client
A
Continue to monitor the client's cardiac status
Inform the client that PVCs are expected after an MI - ANSWER Ask the ED primary
health care provider to check the client
Rationale: The most appropriate action by the nurse would be to ask the ED health care
provider to check the client. PVCs are a result of increased irritability of ventricular cells.
Peripheral pulses may be absent or diminished with the PVCs themselves because the
, decreased stroke volume of the premature beats may in turn decrease peripheral
perfusion. Because other rhythms also cause widened QRS complexes, it is essential that
the nurse determine whether the premature beats are resulting in perfusion of the
extremities. This is done by palpating the carotid, brachial, or femoral artery while
observing the monitor for widened complexes or by auscultating for apical heart sounds.
In the situation of acute MI, PVCs may be considered warning dysrhythmias, possibly
heralding the onset of ventricular tachycardia or ventricular fibrillation. Therefore, the
nurse would not tell the client that the PVCs are expected. Although the nurse will
B
continue to monitor the client and document the findings, these are not the most
appropriate actions of those provided.
LU
NPO status is imposed 8 hours before the procedure on a client scheduled to undergo
electroconvulsive therapy (ECT) at 1 p.m. On the morning of the procedure, the nurse
checks the client's record and notes that the client routinely takes an oral antihypertensive
YC
medication each morning. What action should the nurse take?
Administer the antihypertensive with a small sip of water
Withhold the antihypertensive and administer it at bedtime
D
Administer the medication by way of the intravenous (IV) route
Hold the antihypertensive and resume its administration on the day after the ECT -
TU
ANSWER Administer the antihypertensive with a small sip of water
Rationale: The nurse should administer the antihypertensive with a small sip of water.
General anesthesia is required for ECT, so NPO status is imposed for 6 to 8 hours before
ES
treatment to help prevent aspiration. Exceptions include clients who routinely receive
cardiac medications, antihypertensive agents, or histamine (H2) blockers, which should
be administered several hours before treatment with a small sip of water. Withholding the
antihypertensive and administering it at bedtime and withholding the antihypertensive
C
and resuming administration on the day after the ECT are incorrect actions, because
antihypertensives must be administered on time; otherwise, the risk for rebound
A
hypertension exists. The nurse would not administer a medication by way of a route that
has not been prescribed.
A client who recently underwent coronary artery bypass graft surgery comes to the
primary health care provider's office for a follow-up visit. On assessment, the client tells
the nurse that he is feeling depressed. Which response by the nurse is therapeutic?
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