A practical nurse (PN) is caring for a client who is hours postoperative following an open abdominal procedure. The client is scheduled to receive their routine morning dose of oral lisinopril. The client states, "I feel unusually thirsty and a bit dizzy when I move." The PN obtains the following vital signs: heart rate beats/minute, blood pressure mm Hg, respiratory rate breaths/minute, and oxygen saturation on room air. Which action should the PN take regarding the scheduled medication?
- Withhold the scheduled dose of the medication and immediately report the client's vital signs and symptoms to the registered nurse (RN).Cevap
- BAdminister the medication as prescribed, interpreting the elevated heart rate and slightly low blood pressure as expected postoperative responses.
- CAdminister the medication after solely verifying the client's room number, bypassing the requirement to check two distinct patient identifiers.
- DAccept a verbal order from the surgeon to independently administer an intravenous push fluid bolus to increase the blood pressure.
Cevap
Withhold the scheduled dose of the medication and immediately report the client's vital signs and symptoms to the registered nurse (RN).
The client's presentation of tachycardia, hypotension, dizziness, and thirst hours postoperatively strongly suggests early hypovolemic shock, potentially from occult bleeding or fluid shifts. Lisinopril is an antihypertensive medication. Administering it in this context would further lower the blood pressure, risking severe hypoperfusion and cardiovascular collapse. The safest and most appropriate action within the practical nurse scope of practice is to withhold the dose and immediately notify the registered nurse so a comprehensive assessment and medical interventions can be initiated.
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Safe Medication Administration: Withholding Antihypertensives in Potential Shock