Question

a nurse is preparing to administer a clients antihypertensive medication. when using clinical judgment, which of the following findings indicates the nurse should further assess the client before administering medication?
the client reports dizziness when ambulating to the bathroom.
the client has a urine output of 400 ml for the past 8 hr.
the client reports having trouble sleeping the previous night.
the client ate 60% of their breakfast.

Explanation:

• Dizziness when ambulating may indicate low blood pressure. Administering antihypertensive medication could further lower blood pressure and cause harm.
• A urine output of 400 mL in 8 hours (50 mL/hour) is within the normal range (0.5 - 1 mL/kg/hour for adults, assuming an average adult weight).
• Trouble sleeping is not directly related to the immediate safety of administering antihypertensive medication.
• Eating 60% of breakfast is a normal dietary intake and not a contraindication for antihypertensive medication.

Answer:

The client reports dizziness when ambulating to the bathroom.