A client with heart failure is due to receive enalapril (Vasotec) and has a blood pressure of 98/50 mm Hg. What is the nurse's best action?
a. Administer the Vasotec.
b. Recheck the blood pressure.
c. Hold the Vasotec.
d. Notify the health care provider.
A
The nurse should administer the medication. Generally, the health care provider will maintain the client's blood pressure between 90 and 110 mm Hg.
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After the teaching process is completed, the nurse is careful to:
1. Evaluate the response to teaching. 2. Follow up with the family to see whether the client is following through. 3. Document responses to teaching. 4. Select new strategies for teaching.
The nurse notices that a physician's order for a medication for an elderly patient seems very low. What is the best nursing action?
A) Verify that the low dose is deliberate to compensate for aging. B) Ask the pharmacist for a rationale for the dose. C) Refuse to administer the medication as the dose is too low. D) Ask the physician to increase the dose of the medication.
The nurse demonstrates an understanding of mutuality when stating to the client,
a. "Mr. Jones, I think you should go to bed now." b. "Mr. Jones, I would like you to go to bed now." c. "Mr. Jones, I don't think you should sit in the chair." d. "Mr. Jones, I thought we agreed that you would return to bed at this time."
A nurse in the outpatient pediatric clinic is reviewing the records of a preschool-age child and notes that because the parents often miss routine healthcare visits the child has not received the second measles,mumps, and rubella (MMR) vaccine
The nurse should 1. speak firmly with the parents aboutthe importance of being compliant. 2. notify the physician that the child'simmunizations are no longer up to date. 3. call the parents and encourage themto bring the child for recommended care. 4. plan to discuss the principles ofhealth supervision at the next scheduled visit.