A nurse is monitoring a client who is receiving a unit of packed red blood cells (RBCs) following surgery. Which of the following assessments is an indication that the client might be experiencing circulatory overload?

Bradycardia

Flushing

Vomiting

Dyspnea

Answer and Explanation

The Correct Answer is D

Choice A reason: Bradycardia is not an indication of circulatory overload. Bradycardia is a slow heart rate, usually below 60 beats per minute. Circulatory overload causes the heart to work harder to pump the excess fluid in the blood vessels, which can result in tachycardia, or a fast heart rate, usually above 100 beats per minute.

Choice B reason: Flushing is not an indication of circulatory overload. Flushing is a reddening of the skin, usually due to increased blood flow or inflammation. Circulatory overload causes the blood vessels to constrict and increase the blood pressure, which can result in pallor, or a pale appearance of the skin.

Choice C reason: Vomiting is not an indication of circulatory overload. Vomiting is the forceful expulsion of stomach contents through the mouth, usually due to nausea, infection, or irritation. Circulatory overload does not affect the gastrointestinal system directly, although it may cause abdominal distension or ascites, which is the accumulation of fluid in the abdominal cavity.

Choice D reason: Dyspnea is an indication of circulatory overload. Dyspnea is the sensation of difficulty breathing, usually due to inadequate oxygen delivery to the tissues. Circulatory overload causes the excess fluid in the blood vessels to leak into the lungs, which can result in pulmonary edema, or the accumulation of fluid in the alveoli. This impairs the gas exchange and causes hypoxia, or low oxygen levels in the blood.

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Correct Answer is C

Explanation

Choice A reason: Taking this medication with food is not necessary, as lisinopril can be taken with or without food. Food does not affect the absorption or effectiveness of lisinopril.

Choice B reason: Facial swelling is not an expected effect of this medication, but a serious adverse reaction that indicates angioedema. Angioedema is a life-threatening condition that causes swelling of the face, tongue, throat, and airway. It requires immediate medical attention and discontinuation of lisinopril.

Choice C reason: Reporting a cough to the provider is an important instruction, as a cough is a common and annoying side effect of lisinopril. Lisinopril belongs to the class of angiotensin-converting enzyme (ACE) inhibitors, which can cause a dry, persistent, nonproductive cough. The cough may interfere with the client's quality of life and adherence to the medication. The provider may prescribe an alternative medication, such as an angiotensin II receptor blocker (ARB), to avoid the cough.

Choice D reason: Increasing the intake of potassium-rich foods is not advisable, as lisinopril can cause hyperkalemia (high potassium levels) due to decreased potassium excretion in the urine. Clients should monitor their potassium levels and avoid excessive intake of potassium supplements or foods, such as bananas, oranges, potatoes, and tomatoes.

A. Take this medication with 8 ounces of water. B. Take one tablet at the first indication of chest pain. C. Take one tablet every 15 minutes during an acute attack. D. Take this medication after each meal and at bedtime.

Correct Answer is B

Explanation

Choice A reason: Taking this medication with 8 ounces of water is not necessary. Sublingual nitroglycerin tablets are designed to dissolve under the tongue and be absorbed quickly into the bloodstream. Drinking water may interfere with the absorption and effectiveness of the medication.

Choice B reason: Taking one tablet at the first indication of chest pain is the correct instruction. Sublingual nitroglycerin tablets are used to relieve anginal pain by dilating the coronary arteries and improving blood flow to the heart. The client should place one tablet under the tongue as soon as chest pain occurs and wait for it to dissolve.

Choice C reason: Taking one tablet every 15 minutes during an acute attack is not the correct instruction. Sublingual nitroglycerin tablets have a short duration of action and may not provide adequate relief for a prolonged anginal attack. The client should follow the rule of three: take one tablet every 5 minutes for up to three doses. If the pain is not relieved after three doses, the client should call 911 or seek emergency medical attention.

Choice D reason: Taking this medication after each meal and at bedtime is not the correct instruction. Sublingual nitroglycerin tablets are not used for the prevention of angina. They are only used for the treatment of acute anginal episodes. Taking this medication regularly may cause tolerance and reduce its effectiveness.

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A nurse is monitoring a client who is receiving a unit of packed red blood cells (RBCs) following surgery. Which of the following assessments is an indication that the client might be experiencing circulatory overload?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who has a new prescription for lisinopril. Which of the following statements by the nurse indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse is teaching a client who has angina pectoris about starting therapy with sublingual (SL) nitroglycerin tablets. The nurse should include which of the following instructions regarding how to take the medication?

Correct Answer is B

Explanation

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