A nurse is assessing a client who has hypertension and has started taking lisinopril. Which of the following findings should the nurse report to the provider immediately?

Nausea

Dry cough

Eyelid edema

Insomnia

Answer and Explanation

The Correct Answer is C

Nausea is a common side effect of lisinopril but does not typically require immediate reporting unless severe or persistent.
Dry cough is a common side effect of lisinopril but does not typically require immediate reporting unless severe or persistent.
Eyelid edema can indicate angioedema, a serious adverse reaction to lisinopril that requires immediate medical attention.
Insomnia is not a common side effect of lisinopril and does not typically require immediate reporting.

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Correct Answer is A

Explanation

A. Asking the adolescent to describe the quality of their pain can provide valuable information about the characteristics of the pain, such as sharp, dull, throbbing, or burning.
B. Asking the adolescent to point to the area of most severe pain assesses location, not quality.

C. Asking about pain level assesses intensity, not quality.

D. Asking about the timing of pain increasing assesses onset, not quality.

A. The client had a decreased neutrophil count before the medication was administered. B. The client had chemotherapy 12 hr before the medication was administered. C. The vial was out of the refrigerator for 2 hr before the medication was administered. D. The client reported feeling nauseous after the medication was administered.

Correct Answer is C

Explanation

A. The client had a decreased neutrophil count before the medication was administered: This finding may be expected in a client undergoing cytotoxic chemotherapy and receiving filgrastim to stimulate neutrophil production. It is not an indication for an incident report.
B. The client had chemotherapy 12 hr before the medication was administered: The timing of chemotherapy administration is not typically a reason to complete an incident report unless it conflicts with specific medication guidelines or protocols.
C. The vial was out of the refrigerator for 2 hr before the medication was administered:

Filgrastim should be stored in the refrigerator and protected from light. Allowing the medication vial to be out of the refrigerator for an extended period may compromise its stability and effectiveness, potentially leading to adverse effects or reduced efficacy. Therefore, this finding warrants completion of an incident report.
D. The client reported feeling nauseous after the medication was administered: Nausea is a known side effect of filgrastim and is not typically an indication for completing an incident report unless it is severe or persistent and requires intervention.

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A nurse is assessing a client who has hypertension and has started taking lisinopril. Which of the following findings should the nurse report to the provider immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an adolescent who is receiving treatment for burns and is requesting medication for pain. Which of the following questions should the nurse ask to determine the quality of the adolescent's pain?

Correct Answer is A

Explanation

A nurse is reviewing the medical record of a client who just received a dose of IV filgrastim. The client has cancer and is receiving cytotoxic chemotherapy. For which of the following findings should the nurse complete an incident report?

Correct Answer is C

Explanation

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