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Difficulty: MediumPharmacological Therapies

A 65-year-old client is receiving inpatient care for the management of hypertension and angina. The medication administration record indicates a scheduled dose of oral diltiazem 60 mg60\text{ mg}. Prior to giving the medication, the practical nurse (PN) obtains a heart rate of 52 beats/min and a blood pressure of 94/56 mmHg94/56\text{ mmHg}. The client reports feeling lightheaded when attempting to sit on the edge of the bed. Which action is the priority for the PN?

  1. A
    Record the borderline vital signs in the chart and return in one hour to recheck the blood pressure before taking further action.
  2. B
    Obtain a normal saline fluid bolus and administer it via intravenous push to elevate the client's blood pressure.
  3. C
    Administer the diltiazem immediately without scanning the client's identification band to ensure the medication is given on time.
  4. Withhold the scheduled diltiazem dose and immediately communicate the client's vital signs and symptoms to the registered nurse.Answer

Answer

The priority action is to withhold the scheduled dose of diltiazem and immediately notify the registered nurse of the client's vital signs and symptoms.
Diltiazem is a calcium channel blocker utilized to manage hypertension and angina by relaxing blood vessels and slowing the heart rate. Because the client is currently exhibiting symptomatic bradycardia (a heart rate of 52 beats/min) and hypotension (a blood pressure of 94/56 mmHg94/56\text{ mmHg} with lightheadedness), administering this medication could precipitate a dangerous cardiovascular collapse. The practical nurse's priority is to ensure client safety by withholding the dose and immediately escalating the assessment findings to the registered nurse for further clinical evaluation.

Step-by-Step Solution

1
Evaluate the client's vital signs and reported symptoms prior to medication administration.
The client has a heart rate of 52 beats/min (bradycardia), a blood pressure of 94/56 mmHg94/56\text{ mmHg} (hypotension), and reports lightheadedness.
Diltiazem is a calcium channel blocker that therapeutically lowers heart rate and blood pressure, making pre-administration assessment essential.
2
Determine the appropriate clinical intervention based on the assessment findings.
The medication must be withheld.
Administering a calcium channel blocker to a client who is already hypotensive, bradycardic, and symptomatic can cause severe cardiovascular compromise.
3
Identify the proper chain of command and scope of practice for the practical nurse.
The findings must be immediately reported to the registered nurse.
The registered nurse must evaluate the client's deteriorating condition and coordinate advanced interventions, as treatments like intravenous push medications are outside the practical nurse's scope.

Key Concept

Recognizing adverse cardiovascular effects and pre-administration holding parameters for calcium channel blockers.
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Topics

Pharmacological Therapies

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