A nurse is assessing a client who is taking lisinopril. Which of the following findings should the nurse document in the client's medical record as an adverse effect?

Blood pressure 108/62 mm Hg

Potassium 3.5 mEq/L (3.5 to 5 mEq/L)

Frequent, nonproductive cough

Frequent, painless urination

Answer and Explanation

The Correct Answer is C

A. Blood pressure 108/62 mm Hg: Lisinopril is an antihypertensive, and a systolic BP above 90 mm Hg is typically not considered an adverse effect. Hypotension can occur but is more concerning if it results in symptoms such as dizziness or syncope.

B. Potassium 3.5 mEq/L (3.5 to 5 mEq/L): Lisinopril can cause hyperkalemia, but a potassium level of 3.5 mEq/L is within the normal range. Monitoring potassium levels is essential, but this finding does not indicate an adverse effect.

C. Frequent, nonproductive cough: A dry, persistent cough is a common adverse effect of lisinopril due to the accumulation of bradykinin. It often does not resolve until the medication is discontinued or switched to an alternative, such as an angiotensin receptor blocker (ARB).

D. Frequent, painless urination: Lisinopril does not typically cause increased urination. While it affects renal function, it is more likely to lead to hyperkalemia or reduced glomerular filtration rate in susceptible individuals.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Assess the client's bilateral hand grasp strength: Slurred speech in a client with sickle cell crisis raises concern for stroke due to vaso-occlusion in cerebral vessels. Assessing hand grasp strength helps evaluate for unilateral weakness, a key indicator of stroke, necessitating immediate intervention.

B. Place a padded tongue blade at the client's bedside: There is no indication the client is experiencing a seizure. Seizure precautions are not a priority unless additional neurological symptoms suggest seizure activity.

C. Check the client's bedside glucose level: Hypoglycemia can cause slurred speech, but in a client with sickle cell disease, stroke is a more likely cause. Assessing neurological function should take precedence over checking glucose unless the client has a history of diabetes or other risk factors.

D. Administer flumazenil IV per facility policy to the client: Flumazenil is used to reverse benzodiazepine overdose. There is no indication that the client has received benzodiazepines or is experiencing medication toxicity.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}

Explanation

The nurse should first address the client's chest pain followed by the client's irregular heart rate.

Rationale:

Chest pain is the priority concern as it indicates an acute coronary event (ST-elevation myocardial infarction, STEMI). Immediate interventions such as oxygen, nitroglycerin, and pain management are required to reduce myocardial oxygen demand and prevent further cardiac damage.

Irregular heart rate must be addressed next, as tachycardia and arrhythmias can increase myocardial workload and worsen ischemia. Monitoring and possible antiarrhythmic interventions may be required to stabilize cardiac function.

Incorrect:

Troponin levels: Elevated troponin confirms myocardial injury but does not require immediate intervention; managing the ongoing ischemia is the priority.

Oxygen saturation: The client's oxygen saturation is 93% on room air, which is adequate. Oxygen therapy is not the first priority unless levels drop further.

Hyperlipidemia: While a cardiovascular risk factor, it is not an acute concern during an MI. Long-term management is necessary but not the immediate priority.

C-reactive protein: Elevated CRP indicates inflammation but does not require urgent intervention in the acute phase of MI.

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A nurse is assessing a client who is taking lisinopril. Which of the following findings should the nurse document in the client's medical record as an adverse effect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is experiencing a sickle cell crisis. During morning care, the assistive personnel alerts the nurse that the client is slurring their speech. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is admitting a client who reports tightness in their chest that radiates to left arm. Complete the following sentence by using the lists of options. The nurse should first address the client's ____ followed by the client's ____ .

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}

Explanation

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