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Nure 231-1

The nurse's priority assessment before administering Enalapril maleate is to check the client's blood pressure due to the risk of postural hypotension. For an upper GI series, the client needs further instruction if they believe they need to take citrate of magnesia and a Fleet enema, as no special preparation is required other than maintaining NPO status. If a medication dose appears higher than normal, the nurse should contact the on-call health care provider for clarification rather than wait until the next morning.

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11 views1 page

Nure 231-1

The nurse's priority assessment before administering Enalapril maleate is to check the client's blood pressure due to the risk of postural hypotension. For an upper GI series, the client needs further instruction if they believe they need to take citrate of magnesia and a Fleet enema, as no special preparation is required other than maintaining NPO status. If a medication dose appears higher than normal, the nurse should contact the on-call health care provider for clarification rather than wait until the next morning.

Uploaded by

George
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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Enalapril maleate is prescribed for a hospitalized client.

Which assessment does the nurse perform as a


priority before administering the medication?

Checking the client's blood pressure

Rationale: Enalapril maleate is an angiotensin-converting enzyme (ACE) inhibitor used to treat


hypertension. One common side effect is postural hypotension. Therefore the nurse would check the
client's blood pressure immediately before administering each dose. Checking the client's peripheral
pulses, the results of the most recent potassium level, and the intake and output for the previous 24
hours are not specifically associated with this mediation.

A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse provides
instructions to the client about the test. Which statement by the client indicates a need for further
instruction?

"I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on the
morning of the test."

Rationale: An upper GI series involves visualization of the esophagus, duodenum, and upper jejunum by
means of the use of a contrast medium. It involves swallowing a contrast medium (usually barium),
which is administered in a flavored milkshake. Films are taken at intervals during the test, which takes
about 30 minutes. No special preparation is necessary before a GI series, except that NPO status must
be maintained for 8 hours before the test. After an upper GI series, the client is prescribed a laxative to
hasten elimination of the barium. Barium that remains in the colon may become hard and difficult to
expel, leading to fecal impaction.

A nurse on the evening shift checks a health care provider's prescriptions and notes that the dose of a
prescribed medication is higher than the normal dose. The nurse calls the health care provider's
answering service and is told that the health care provider is off for the night and will be available in the
morning. The nurse should:

Ask the answering service to contact the on-call health care provider

Rationale: The nurse has a duty to protect the client from harm. A nurse who believes that a health care
provider's prescription may be in error is responsible for clarifying the prescription before carrying it
out. Therefore the nurse would not administer the medication; instead, the nurse would withhold the
medication until the dose can be clarified. The nurse would not wait until the next morning to obtain
clarification. It is premature to call the nursing supervisor.

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