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. Discuss events with the child that have led to anxiety in the past.: While understanding past anxiety triggers can be helpful, focusing on specific strategies and action plans is more effective for managing current anxiety.

B. Assure the child that he is in control of the situation.: This might not always be accurate or helpful. Reassuring the child may not address the underlying anxiety or provide practical strategies for managing it.

C. Provide the child with a detailed action plan when he becomes anxious.: This approach is beneficial as it gives the child a structured plan to follow, which can help manage anxiety and provide a sense of control. Specific actions can help the child cope with anxiety in real-time.

D. Leave the child alone when he is exhibiting signs of anxiety.: Avoiding the child during episodes of anxiety can increase feelings of isolation and might not address the child's needs for support and guidance during these times.

A. "Tilt the spirometer toward yourself so you can see the balls rise." B. "Inhale deeply and hold each breath for a minimum of 10 seconds." C. "Exhale before sealing your lips around the mouthpiece." D. "Use your incentive spirometer every 4 hours while you are awake."

Correct Answer is D

Explanation

A) "Tilt the spirometer toward yourself so you can see the balls rise": Tilting the spirometer is not necessary and may affect its accuracy. The spirometer should be held in an upright position to ensure correct measurement of inhalation.

B) "Inhale deeply and hold each breath for a minimum of 10 seconds": Inhaling deeply is important, but holding each breath for 10 seconds is not a typical recommendation for using an incentive spirometer. The goal is to inhale deeply and slowly, without necessarily holding the breath for an extended period.

C) "Exhale before sealing your lips around the mouthpiece": Exhaling before using the spirometer is not recommended. The correct procedure involves inhaling deeply and slowly after sealing your lips around the mouthpiece to ensure accurate measurement and effective lung expansion.

D) "Use your incentive spirometer every 4 hours while you are awake": Frequent use of the incentive spirometer, often every hour while awake, is recommended to improve lung function and prevent complications such as atelectasis. Using it every 4 hours may not be sufficient for effective respiratory therapy.

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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?

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