A nurse is assessing a client who is taking telmisartan. The nurse should identify that which of the following findings indicates that the medication has been effective?
Respiratory rate of 16/min
Decrease in blood pressure
Increase in urinary output
Blood glucose of 110 mg/dL
The Correct Answer is B
Telmisartan is an angiotensin II receptor blocker (ARB) used to treat hypertension by lowering blood pressure. Therefore, a decrease in blood pressure would suggest that the medication is working as intended.
Telmisartan has no effect on respiratory rate, urine output or blood glucose.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E","F"]
Explanation
The client is likely suffering from diabetes ketoacidosis with metabolic acidosis not respiratory alkalosis. They are also severely dehydrated which may lead to hypotension and acute renal injury. In DKA, clients may have hyperkalemia or hypokalemia who h may predispose to cardiac dysrhythmias.
Septic shock is unlikely as the chest exam indicates likely resolved pneumonia.
Cerebral edema is commonly seen in clients on hydration therapy in DKA due to rapid fluid replacement.
Correct Answer is B
Explanation
B. Ensuring that there is space for one finger to fit between the vest and the client's skin helps prevent skin breakdown and pressure injuries. The halo vest should fit snugly but not too tight to allow for proper circulation and comfort.
A. Moving the client by holding onto the halo traction device can disrupt the device's stability and potentially cause harm to the client.
C. Applying medicated powder under the vest can introduce foreign substances to the skin and may increase the risk of skin irritation or infection.
D. This should only be performed under the guidance of a healthcare provider.
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