Prior to the administration of a beta-adrenergic blocker, the nurse notes the patient to have a heart rate of 52 beats/min, peripheral edema, crackles in the bases of the lungs, and mottled skin. Which is the priority nursing action?
a. Administer the medication as ordered.
b. Reevaluate the patient in 20 minutes.
c. Obtain a serum blood level.
d. Withhold the medication and notify the health care provider.
ANS: D
These symptoms warrant the nurse's withholding the dose and then notifying the health care provider. The medication should not be administered if the patient's heart rate is low or the patient is experiencing symptoms of heart failure and poor perfusion. The patient should be assessed frequently after the medication is held and the health care provider is notified, but action needs to be taken immediately. Therapeutic blood levels for beta-adrenergic medications are not typically measured.
You might also like to view...
A 9-year-old boy is taking testosterone injections for treatment of hypogonadism. What should be measured every 6 months on this child?
A) Liver function test (LFT) B) Cholesterol level C) Vision D) Hand and wrist radiographs
A school-age child is scheduled for a tonsillectomy. What should the nurse assess prior to the surgery being done?
A) Urine specific gravity B) Pulse and respiratory rate C) Bleeding and clotting time D) Lying and sitting blood pressure
The nurse is using the neuromatrix theory when determining a patient's pain. What should the nurse consider when assessing a patient's pain?
1. cultural and genetic factors 2. specificity 3. pattern 4. previous sensitization
A nurse is developing a nursing plan of care for a client at risk for a pressure ulcer. Which of the below should be included in the plan? (Select all that apply.)
a. Perform a skin risk assessment. b. Place a plastic sheet on the bed to protect the mattress. c. Allow the client to sit on the bedpan for as long as the client feels the need to void. d. Place a pressure-relieving mattress on client's bed e. Apply a moisture barrier cream to client after each incontinent episode.