A nurse is reviewing the medication administration record (MAR) of a client who has hypertension. The nurse notices that the client has been prescribed both lisinopril and spironolactone. Which of the following actions should the nurse take?
Administer both medications as ordered
Hold both medications and notify the provider
Hold lisinopril and administer spironolactone
Hold spironolactone and administer lisinopril
The Correct Answer is B
Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor that lowers blood pressure by blocking the conversion of angiotensin I to angiotensin II, which causes vasoconstriction. Spironolactone is a potassium-sparing diuretic that lowers blood pressure by increasing urine output and preventing sodium and water reabsorption.
However, both medications can also increase potassium levels in the blood, which can lead to hyperkalemia, a potentially life-threatening condition. The nurse should hold both medications and notify the provider of this potential drug interaction.
Incorrect choices:
a) Administer both medications as ordered: This is incorrect as it exposes the client to the risk of hyperkalemia.
c) Hold lisinopril and administer spironolactone: This is incorrect as it does not eliminate the risk of hyperkalemia from spironolactone alone.
d) Hold spironolactone and administer lisinopril: This is incorrect as it does not eliminate the risk of hyperkalemia from lisinopril alone.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Maintaining the current oxygen flow rate is the appropriate action for the nurse to take. Clients who have COPD have chronically low oxygen saturation levels and high carbon dioxide levels due to impaired gas exchange. Increasing the oxygen flow rate can cause oxygen toxicity and suppress the respiratory drive, leading to respiratory failure. The nurse should aim to keep the oxygen saturation level between 88% and 92% for clients who have COPD.
Incorrect choices:
a) Increase the oxygen flow rate to 4 L/min: This is incorrect as it can cause oxygen toxicity and suppress the respiratory drive, leading to respiratory failure.
b) Encourage the client to cough and deep breathe: This is incorrect as it can increase the work of breathing and cause fatigue and dyspnea in clients who have COPD.
c) Administer bronchodilator medication as prescribed: This is incorrect as it does not address the immediate issue of low oxygen saturation level. Bronchodilator medication can help improve airflow and reduce airway inflammation, but it does not directly increase oxygen delivery.
Correct Answer is A
Explanation
Prothrombin time (PT) is a measure of how long it takes for blood to clot. Warfarin is an anticoagulant that prolongs the PT and prevents blood clots from forming. The nurse should monitor the PT and adjust the warfarin dose accordingly to maintain a therapeutic range.
Incorrect choices:
b) Activated partial thromboplastin time (aPTT): aPTT is another measure of blood clotting time, but it is used to monitor heparin therapy, not warfarin therapy.
c) Platelet count: Platelet count is a measure of how many platelets are in the blood. Platelets are involved in blood clotting, but they are not affected by warfarin therapy.
d) Hemoglobin level: Hemoglobin level is a measure of how much oxygen-carrying protein is in the blood. Haemoglobin level can be affected by bleeding or anaemia, but it is not directly related to warfarin therapy.
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