A client is prescribed lisinopril 20 mg PO daily for the treatment of hypertension. Which finding would alert the nurse that a side effect of the medication has occurred?

Blood pressure of 120/80 mmHg.

Serum potassium of 5.5 mEq/L.

Heart rate of 80 beats per minute.

Respiration rate of 16 breaths per minute.

Answer and Explanation

The Correct Answer is B

Choice A Reason
A blood pressure of 120/80 mmHg is considered within the normal range and is an ideal target for most individuals being treated for hypertension. This finding would not typically alert the nurse to a side effect of lisinopril.

Choice B Reason
Serum potassium of 5.5 mEq/L is higher than the normal range, which is typically between 3.5 and 5.0 mEq/L. Lisinopril can cause hyperkalemia, which is an elevated level of potassium in the blood. This is a known side effect of lisinopril, especially in clients with renal impairment, as it inhibits the renin-angiotensin-aldosterone system and reduces potassium excretion.

Choice C Reason
A heart rate of 80 beats per minute is within the normal range for adults, which is typically 60-100 beats per minute at rest. This finding would not alert the nurse to a side effect of lisinopril.

Choice D Reason
A respiration rate of 16 breaths per minute is within the normal range for adults, which is typically 12-20 breaths per minute at rest. This finding would not alert the nurse to a side effect of lisinopril.

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Correct Answer is D

Explanation

Choice A Reason
Applying cool compresses to the affected limb can help reduce swelling and provide pain relief. However, it's important to follow the surgeon's specific postoperative orders, as the application of cold can vary depending on the surgical technique and patient's condition.

Choice B Reason
Placing a soft pillow under the knee is not recommended after total knee replacement surgery. This position can lead to decreased range of motion and contractures. The knee should be kept in a more extended position to promote healing and mobility.

Choice C Reason
Promoting bedrest for an extended period is not typically advised following knee replacement surgery. Early mobilization is important to prevent complications such as deep vein thrombosis and to encourage circulation and healing. The duration of bedrest should be as per the surgeon's protocol.

Choice D Reason
Encouraging increased fluid intake is important after surgery to prevent dehydration, promote kidney function, and ensure adequate blood volume and circulation. Proper hydration is essential for healing and can help with the metabolism of medications used during and after surgery.

A. Information about available community resources. B. When to return to the ED for follow-up care. C. Names and phone numbers of local attorneys who defend rape victims. D. The phone number of the battered women's shelter or safe house.

Correct Answer is A

Explanation

Choice A reason:
Providing information about available community resources is crucial for ongoing support and assistance. These resources can offer counseling, medical follow-up, legal advice, and other services that may be needed after such a traumatic event. Community resources play a vital role in the recovery process, offering a network of support and specialized services tailored to the needs of sexual assault survivors.

Choice B reason:
While it is important to know when to return to the ED for follow-up care, this is typically not the primary content of discharge instructions. Follow-up care is usually managed by primary care providers or specialists rather than the ED unless there are specific complications or concerns that need to be addressed immediately.

Choice C reason:
The names and phone numbers of local attorneys may be provided, but this is not standard for all discharge instructions. Legal support is important, but the immediate focus post-discharge is often on the survivor's physical and emotional well-being. Attorneys specializing in defending rape victims can be a part of the community resources provided to the survivor.

Choice D reason:
The phone number of a battered women's shelter or safe house may be included in discharge instructions, especially if there is an immediate need for safe accommodation. However, this is not the only resource that should be provided, and it is not specific to all cases of sexual assault.

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A client is prescribed lisinopril 20 mg PO daily for the treatment of hypertension. Which finding would alert the nurse that a side effect of the medication has occurred?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Eight hours postoperative following a total knee replacement, which intervention should the nurse implement for the client?

Correct Answer is D

Explanation

After examining and treating a client who has been raped, discharge instructions from the emergency department (ED) would include which of the following?

Correct Answer is A

Explanation

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