Examkin

Question

Difficulty: MediumPharmacological Therapies

An adult client is prescribed a daily dose of oral diltiazem for the management of hypertension. Prior to providing the morning dose, the practical nurse (PN) obtains a blood pressure reading of 88/5488/54 mm Hg and an apical heart rate of 5858 beats/min. Which of the following actions should the PN perform?

  1. A
    Instruct a nursing assistant to repeat the blood pressure measurement in thirty minutes.
  2. B
    Provide the medication as prescribed and record the physiological data in the client's health record.
  3. Pause the administration and alert the registered nurse regarding the client's current vital signs.Answer
  4. D
    Place the tablet on the bedside table and advise the client to take it once they feel less dizzy.

Answer

The most appropriate action is to pause the administration and notify the registered nurse about the low blood pressure and heart rate.
The correct action is to pause the administration and alert the registered nurse. Diltiazem is a calcium channel blocker that decreases heart rate and blood pressure. Because the client is currently hypotensive (88/5488/54 mm Hg) and bradycardic (5858 beats/min), giving the medication could lead to severe, life-threatening cardiovascular depression. The practical nurse must prioritize client safety by holding the medication and promptly reporting the abnormal findings to the supervising registered nurse for further clinical decision-making.

Step-by-Step Solution

1
Analyze the current vital signs against the anticipated effects of the prescribed medication.
The blood pressure of 88/5488/54 mm Hg is low (hypotension), and the heart rate of 5858 beats/min is low (bradycardia). Diltiazem lowers both of these parameters.
Understanding the pharmacodynamics of a drug is essential before administration to prevent adverse outcomes.
2
Determine if the medication is safe to give under the current clinical conditions.
It is unsafe to administer the diltiazem because it will exacerbate the client's existing hypotension and bradycardia.
Client safety dictates that medications with depressive effects on the cardiovascular system must be held if baseline parameters are too low.
3
Select the nursing action that aligns with the practical nurse (PN) scope of practice.
The PN must withhold the medication and escalate the critical findings to the registered nurse for further medical evaluation.
The PN is responsible for recognizing abnormal findings, ensuring immediate safety by holding the drug, and collaborating with the RN for advanced assessment.

Key Concept

Pharmacological safety and nursing scope of practice when administering antihypertensive medications to a hemodynamically unstable client.
Estimated Time:1m 15s
Rate this question

Topics

Pharmacological Therapies

More questions from this topic