HESI EXIT COMPREHENSIVE REVIEW A
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1. The nurse is correct in withholding an older adult client's dose of nifedipine if which assessment finding is obtained? A. Blood pressure of 90/56 mm Hg B. Apical pulse rate of 68 beats/min C. ... Potassium level of 3.3 mEq/L D. Urine output of 200 mL in 4 hours Rationale: Nifedipine is a calcium channel blocker that causes a decrease in blood pressure. It should be withheld if the blood pressure is lowered, and 90/56 mm Hg is a low blood pressure for an adult male. A pulse rate <60 beats/min is an indication to withhold the drug. A potassium level of 3.3 mEq/L is low (normal, 3.5 to 5.0 mEq/L), but this finding does not affect the administration of Procardia. Urine output of more than 30 mL/hr, or 120 mL in 4 hours, is normal. Although a 200-mL output in 4 hours is slightly less than normal and warrants follow-up, it is not an indication to withhold a nifedipine (Procardia) dose. 2. Until the census on the obstetrics (OB) unit increases, an unlicensed assistive personnel (UAP) who usually works in labor and delivery and the newborn nursery is assigned to work on the postoperative unit. Which [Show More]
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