The nurse cares for a client receiving an antihypertensive medication. What is the nurse's priority assessment?
1. Dizziness
2. Vital signs
3. Urine output
4. Serum studies
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2 and 3. The most important nursing assessment is to check vital signs, especially the blood pressure and heart rate because the therapeutic response of an antihypertensive medication is a lower blood pressure; as reflex action, the heart rate can increase as the blood pressure drops to compensate for the drop in cardiac output. As part of the preadministration assessment, the nurse checks the acceptable blood pressure range set by the provider and compares the client's most recent blood pressure with the range. In lieu of a range, the nurse uses clinical judgment and client assessment data, including blood pressure, heart rate, urine output, and level of consciousness, to de-termine whether the nurse should administer the antihypertensive medication. The nurse reports a blood pressure less than 90 mm Hg systolic because the client needs a blood pressure of 80 mm Hg or greater to perfuse the kidneys and produce urine. Conversely, the nurse reports a client blood pressure greater than the client's baseline blood pressure, before therapy began, because this potentially indicates the medica-tion is ineffective.
1. An adverse effect of many antihypertensive medications especially when initiating therapy, is dizziness from a lower blood pressure and occurs before the client's com-pensatory mechanisms activate. The nurse can administer a medication with dizziness in the absence of hypotension; however, the nurse must instruct the client to ask for help before getting up and to change positions slowly.
4. If the antihypertensive medication is a diuretic, the nurse checks serum electrolytes including potassium and sodium; thus, checking serum electrolyte studies can be un-necessary.
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