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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is A
Explanation
A) Identify the client's preferred relaxation technique to use prior to each step of the therapy:
Systematic desensitization involves gradually exposing the client to the anxiety-inducing stimulus while using relaxation techniques to manage anxiety. Identifying the client's preferred relaxation technique is crucial to help them remain calm and reduce their phobia-related anxiety during each step of the therapy.
B) Administer an anxiolytic medication 1 hr prior to the scheduled therapy session:
While anxiolytic medications can help reduce anxiety, systematic desensitization typically relies on non-pharmacological methods to help the client gradually overcome their phobia. The goal is for the client to develop coping mechanisms without medication.
C) Expose the client to an excess amount of anxiety-inducing stimulus to extinguish the phobia:
Exposing the client to an excess amount of anxiety-inducing stimuli is not appropriate for systematic desensitization. This method, known as flooding, can overwhelm the client and increase their anxiety, potentially worsening the phobia rather than alleviating it.
D) Ask the client to snap a rubber band worn on the wrist to minimize anxiety when thinking about the phobia:
Snapping a rubber band on the wrist is a distraction technique that might provide temporary relief from anxiety. However, it is not a core component of systematic desensitization, which focuses on gradual exposure and the use of relaxation techniques to manage anxiety
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