A client on a beta blocker has a blood pressure of 90/60 mm Hg. What is the nurse's priority action?

Correct Answer: A

Rationale: The correct answer is A: Hold the beta blocker and notify the healthcare provider. A blood pressure of 90/60 mm Hg is considered low and may be a sign of hypotension, which can be a serious side effect of beta blockers. Holding the medication and notifying the healthcare provider is the priority action to prevent further complications. Administering the beta blocker (choice B) can worsen the hypotension. Administering a diuretic (choice C) may further lower the blood pressure. Continuing to monitor and reassess (choice D) is not appropriate in this situation as immediate action is needed due to the low blood pressure reading.

Correct Answer: A

Rationale: Rationale: 1. Furosemide is a loop diuretic that can cause potassium loss. 2. Potassium level of 2.9 mEq/L indicates hypokalemia, which can lead to serious complications. 3. Priority is to address low potassium levels to prevent adverse effects like cardiac arrhythmias. 4. Administering potassium supplements helps to normalize potassium levels promptly. Summary: B: Holding furosemide without addressing low potassium can worsen the imbalance. C: Continuing the current dose without addressing low potassium can lead to further depletion. D: Decreasing furosemide dose before addressing low potassium can delay correcting the imbalance.

Correct Answer: A

Rationale: The correct answer is A: Blood pressure. When administering dobutamine, a medication that increases heart contractility, the most important parameter to assess is blood pressure. This is because dobutamine can cause significant changes in blood pressure, including hypotension or hypertension, which can have serious implications for the client's hemodynamic stability. Monitoring blood pressure allows for timely intervention and adjustment of the medication dosage to ensure optimal cardiovascular function. Heart rate (B), oxygen saturation (C), and respiratory rate (D) are also important parameters to monitor but are not the primary concern when administering dobutamine, as its effects on blood pressure are more critical for patient safety and treatment efficacy.

Correct Answer: A

Rationale: The correct response is A: Advise the client to rise slowly to prevent dizziness. Nitroglycerin patches can cause orthostatic hypotension, leading to dizziness when standing up quickly. By advising the client to rise slowly, the nurse can help prevent a sudden drop in blood pressure and reduce the risk of dizziness and falls. This response promotes client safety and addresses the underlying cause of the symptom. Choices B, C, and D are incorrect: B: Instructing the client to discontinue nitroglycerin patches is not appropriate without consulting the healthcare provider. Abruptly stopping nitroglycerin can lead to serious complications. C: Encouraging the client to rest and avoid physical activity does not address the issue of orthostatic hypotension caused by nitroglycerin patches. D: Suggesting an over-the-counter antiemetic is not indicated for dizziness related to orthostatic hypotension. It does not address the underlying cause

Correct Answer: A

Rationale: The correct answer is A: Administer vitamin K. When a client on warfarin has an INR of 4.5, it indicates over-anticoagulation, putting them at risk of bleeding. Vitamin K helps reverse the effects of warfarin by promoting clotting factors. Administering vitamin K will lower the INR back into the therapeutic range. Holding the next dose of warfarin (B) is not enough to rapidly reverse the effects. Increasing the dose of warfarin (C) would worsen the over-anticoagulation. Monitoring the INR closely (D) is important but not the immediate action needed for a high INR.