Question

The nurse is preparing to administer diltiazem to a client with heart disease. Which action should the nurse take first?

A
Assess the client's urine output and potassium level
B
Assess the client's blood pressure and apical pulse Correct Answer (Blank)
C
Auscultate the abdomen for bowel sounds
D
Assess the client's lung sounds and monitor for wheezing

Answer 1

Before administering diltiazem to a client with heart disease, the nurse's first step is to assess the patient's blood pressure and apical pulse to ensure the safety and appropriateness of the medication.

Step-by-step explanation:

The nurse is preparing to administer diltiazem to a client with heart disease. The first action the nurse should take is to assess the client's blood pressure and apical pulse. This is because diltiazem is a medication that affects the heart and blood vessels, and it is crucial to know the patient's current cardiac state before administering the drug.

Blood pressure assessment involves wrapping an inflatable cuff around the patient's arm at the level of the heart, inflating it to restrict blood flow, and then slowly releasing the air while listening for Korotkoff sounds with a stethoscope. This process gives insight into the arterial pressure. Auscultating the apical pulse involves listening to the heart sounds at the apex of the heart with a stethoscope. This gives information about the heart's rhythm and rate, which are vital to know before giving a cardiac-affecting medication like diltiazem.