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 mm Hg and an apical heart rate of beats/min. Which of the following actions should the PN perform?
- AInstruct a nursing assistant to repeat the blood pressure measurement in thirty minutes.
- BProvide the medication as prescribed and record the physiological data in the client's health record.
- Pause the administration and alert the registered nurse regarding the client's current vital signs.Cevap
- DPlace the tablet on the bedside table and advise the client to take it once they feel less dizzy.
Cevap
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 ( mm Hg) and bradycardic ( 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.
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Anahtar Kavram
Pharmacological safety and nursing scope of practice when administering antihypertensive medications to a hemodynamically unstable client.
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