HESI bsn 225 RN Pharmacology Proctored Exam
The nurse prepares to administer a scheduled dose of labetalol PO to a client with hypertension. The client's vital signs are a temperature of 99° F (37.2° C), a heart rate of 48 beats/minute, respirations of 16 breaths/minute, and a blood pressure of 150/90 mm Hg. Which action should the nurse take?
Explanation & Rationale
A. Applying a telemetry monitor is not necessary unless there are specific concerns about the client's heart rhythm or additional monitoring requirements. B. While assessing for orthostatic hypotension is important in general, the heart rate of 48 beats/minute is a critical finding that needs immediate attention. C. Administering the dose without addressing the bradycardia could exacerbate the low heart rate, so monitoring alone is insufficient. D. Withholding the dose and notifying the healthcare provider is appropriate due to the client's bradycardia (heart rate of 48 beats/minute), which is a significant concern with beta-blockers like labetalol.
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