A nurse is monitoring a client who is taking captopril and has developed swelling of the lips and tongue. Which of the following actions should the nurse plan to take to manage this adverse medication reaction?

Administer a dose of subcutaneous epinephrine.

Advise the client not to consume grapefruit products.

Place warm compresses on both sides of the client's face.

Swab the client's oral mucosa with nystatin suspension.

Answer and Explanation

The Correct Answer is A

A. Administer a dose of subcutaneous epinephrine.: The swelling of the lips and tongue is indicative of angioedema, a serious adverse reaction to captopril. Epinephrine is the first-line treatment for severe allergic reactions or angioedema to quickly counteract the swelling and prevent airway obstruction.

B. Advise the client not to consume grapefruit products.: Grapefruit can interact with some medications, but it is not related to the management of angioedema. This action would be more relevant for drugs metabolized by CYP3A4, not specifically for angioedema.

C. Place warm compresses on both sides of the client's face.: Warm compresses are not appropriate for angioedema and may not address the underlying issue. This action does not manage the immediate, potentially life-threatening reaction caused by captopril.

D. Swab the client's oral mucosa with nystatin suspension.: Nystatin is used for fungal infections of the oral mucosa, not for angioedema. This action does not address the adverse reaction related to captopril.

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Correct Answer is C

Explanation

A) "Gestational diabetes increases the risk of your baby having hemorrhagic disease after birth." Hemorrhagic disease of the newborn is typically related to vitamin K deficiency, not gestational diabetes. Thus, this response does not directly address the risks associated with gestational diabetes.

B) "Gestational diabetes increases the risk of your baby having a cleft lip or palate." Cleft lip and palate are congenital conditions that are more related to genetic and environmental factors during the early stages of pregnancy. Gestational diabetes does not increase the risk of these specific congenital abnormalities.

C) "Gestational diabetes increases the risk of your baby having hypoglycemia after birth." This is correct. Infants born to mothers with gestational diabetes are at risk for hypoglycemia shortly after birth due to the high levels of insulin produced in response to maternal hyperglycemia during pregnancy.

D) "Gestational diabetes increases the risk of your baby having a low birth weight." Gestational diabetes more commonly leads to macrosomia (large birth weight) rather than low birth weight. The excessive glucose levels in the mother’s blood can result in increased fetal insulin production, leading to increased growth and fat deposits.

A. Drink 8 oz of milk when hypoglycemia develops. B. Initiate a 1,400-calorie diet daily. C. Rotate the insulin injection site to a different area of the body with every other injection. D. Keep unopened insulin refrigerated at 4.44° C (40° F).

Correct Answer is D

Explanation

A) Drink 8 oz of milk when hypoglycemia develops:
While consuming a fast-acting carbohydrate is important during hypoglycemia, 8 oz of milk may not be the most effective choice. Typically, glucose tablets or juice are recommended as they provide a quicker absorption of sugar into the bloodstream.

B) Initiate a 1,400-calorie diet daily:
Caloric needs should be individualized based on the adolescent’s age, weight, activity level, and overall health. A fixed 1,400-calorie diet might not be appropriate for every adolescent and could lead to insufficient energy intake or excessive restriction.

C) Rotate the insulin injection site to a different area of the body with every other injection:
While rotating injection sites is important to prevent lipodystrophy, it is generally recommended to use different sites within the same area (such as different spots on the abdomen) rather than entirely different areas of the body with each injection. This ensures consistent absorption of insulin.

D) Keep unopened insulin refrigerated at 4.44° C (40° F):
Unopened insulin should be stored in the refrigerator to maintain its potency until it is ready to be used. This temperature range ensures the insulin remains stable and effective for use.

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A nurse is monitoring a client who is taking captopril and has developed swelling of the lips and tongue. Which of the following actions should the nurse plan to take to manage this adverse medication reaction?

Nursing Test Bank

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