A client with hypertension has experienced heart failure. The nurse notes that the client is receiving nifedipine (Procardia). Which is a priority assessment for the nurse?
1. Auscultate breath sounds for crackles.
2. Assess level of orientation.
3. Review recent lab results for hypokalemia.
4. Assess urinary output.
Correct Answer: 1
Rationale 1: Some calcium channel blockers can reduce myocardial contractility and can worsen heart failure. Crackles in the lungs can indicate pulmonary edema, which could indicate heart failure.
Rationale 2: Level of orientation could be decreased with heart failure, but it is not a priority assessment at this time.
Rationale 3: Calcium channel blockers do not cause hypokalemia.
Rationale 4: Urinary output could be decreased with heart failure, but it is not a priority assessment at this time.
Global Rationale: Some calcium channel blockers can reduce myocardial contractility and can worsen heart failure. Crackles in the lungs can indicate pulmonary edema, which could indicate heart failure. Level of orientation could be decreased with heart failure, but it is not a priority assessment at this time. Calcium channel blockers do not cause hypokalemia. Urinary output could be decreased with heart failure, but it is not a priority assessment at this time.
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