The nurse wants to transfer the client to the chair and the client receives an antihypertensive medication. Which clinical indicator from the client cues the nurse to increase preventive meas-ures for client injury during a transfer?

Question

1. Hypokalemia
2. Facial redness
3. Sinus tachycardia
4. Mild peripheral edema

Answer 1

2
2. Sinus tachycardia is usually a clinical indicator of another problem such as pain, hypovolemia, hypoxia, anemia, and anxiety, or it can be a physiological response to exercise; so, the nurse should assess the client's pain level, fluid volume status, he-moglobin level, oxygen saturation, and anxiety to help rule out potential causes of sinus tachycardia. The nurse plans to prevent orthostatic hypotension for the client who receives antihypertensive therapy and who has sinus tachycardia, a heart rate greater than 100, because a heart beating abnormally fast has less time for ventricular filling and thereby less blood volume to eject. This decreases the cardiac output and the ability of the client to maintain adequate blood flow to the brain through com-pensatory mechanisms while moving. To prevent client injury during the transfer, the nurse moves the client from one position to another slowly; questions the client about dizziness, lightheadedness, nausea, and fears or concerns; observes for pallor and loss of consciousness; monitors the blood pressure closely; and, if necessary, delays the transfer to another time. To transfer, the nurse instructs the client to rhythmically tighten and relax muscles or to flex and extend joints of the lower extremities to faci-litate venous blood return to the heart and benefit from compensatory mechanisms. If the nurse administers the antihypertensive agent within four hours of the transfer, the nurse notes the client's response to the medication, delays the transfer if necessary, and uses the information to plan another transfer. The client may need additional time to adjust to the medication or the dosage, more fluid, a slower transfer, or physical therapy to increase muscle bulk and tone before the next transfer.
1. Facial redness can be a normal response to activity, hyperthermia, infection, and inflammation. When the blood pressure drops as with orthostatic hypotension, the client's skin becomes pale.
3. Mild peripheral edema, a potential adverse effect of a few antihypertensive agents, usually does not increase a client's risk for injury during a transfer.
4. Hypokalemia, a potential adverse effect of some antihypertensive agents, usually does not increase the client's risk for injury during a transfer unless the low potassium level leads to ventricular arrhythmias significant enough to decrease cardiac output.