the nurse is correct in withholding which medication if the clients blood pressure is 8850
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Nursing Elites

NCLEX-PN

Kaplan NCLEX Question of The Day

1. Which medication should the nurse withhold if the client's blood pressure is 88/50?

Correct answer: B

Rationale: Enalapril (Vasotec) is the correct answer. It is an angiotensin-converting enzyme (ACE) inhibitor that can further lower blood pressure. Given that the client's blood pressure is already low at 88/50, administering Enalapril could exacerbate hypotension and compromise perfusion to vital organs. Rosuvastatin (Crestor), Digoxin (Lanoxin), and Clopidogrel (Plavix) are not contraindicated in the context of low blood pressure and may be administered safely.

2. What is the preferred position for a client post liver biopsy procedure?

Correct answer: B

Rationale: The correct position for a client post liver biopsy procedure is the right side. Placing the client on the right side helps apply pressure to the liver area, which can help in holding pressure and stopping bleeding. Placing the client on the left side may not be as effective in providing direct pressure on the liver. The prone position is also not ideal for post-liver biopsy care as it does not target the liver area directly. Fowler's position, a semi-sitting position, is not typically recommended post liver biopsy as it does not provide the necessary pressure on the liver site.

3. A healthcare professional is reviewing a patient's serum glucose levels. Which of the following scenarios would indicate abnormal serum glucose values for a 30-year-old male?

Correct answer: B

Rationale: The correct answer is 55 mg/dL. The standard range for serum glucose levels is typically 60-115 mg/dL. A serum glucose level of 55 mg/dL falls below this range, indicating hypoglycemia. Options A, C, and D are within the standard range for serum glucose levels and would not be considered abnormal for a 30-year-old male.

4. The client with peripheral vascular disease is reviewing self-care measures. Which of the following statements indicates proper self-care measures?

Correct answer: D

Rationale: The correct answer is, "I have my wife examine the soles of my feet each day."? Clients with peripheral vascular disease should examine their feet daily for any signs of redness, dryness, or cuts. If the client is unable to do this themselves due to decreased sensation in their feet, a caregiver or family member should assist. Soaking feet in a hot tub should be avoided as the client may not be able to sense if the water is too hot, potentially causing burns. Walking barefoot can lead to injuries, so wearing shoes or slippers is recommended to minimize trauma. While quitting smoking is a positive step, using chewing tobacco can still constrict blood vessels, adversely affecting circulation in the extremities.

5. What should the nurse do while caring for a client with an eating disorder?

Correct answer: D

Rationale: The correct answer is to monitor food intake and behavior for one hour after meals. This is crucial in caring for a client with an eating disorder as it helps in assessing any immediate risks related to the disorder. Option A is incorrect as it may trigger additional stress for the client and distract from the main focus of managing the disorder. Option B, weighing the client daily, could lead to an unhealthy focus on weight and potentially worsen the client's mental health. Option C, restricting access to mirrors, although it may be beneficial for body image concerns, does not directly address the core issue of monitoring food intake and behavior, which is essential in managing eating disorders.

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