A patient with heart failure has met with their primary provider and begun treatment with an angiotensin-converting enzyme (ACE) inhibitor. When the patient begins treatment, which assessment should the nurse prioritize?
Oxygen saturation.
Blood pressure.
Level of consciousness.
Assessment for nausea.
The Correct Answer is B
When a patient with heart failure begins treatment with an ACE inhibitor, the nurse should prioritize monitoring the patient's blood pressure because ACE inhibitors can cause hypotension. Oxygen saturation, choice A, may be important to monitor in some cases, but it is not the priority in this situation. Level of consciousness, choice C, and assessment for nausea, choice D, may also be important but are not the priority assessments in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
When an assistive personnel expresses concerns or vents about client behaviors, a therapeutic response is necessary. Asking the AP to explain or to further describe his or her thoughts, feelings, or concerns will allow the AP to reflect on these issues and help clarify any misconceptions or misunderstandings. The nurse's response should be nonjudgmental, noncritical, and focused on the AP's perceptions and feelings.
Option A is confrontational and Option C is inappropriate because it suggests that the AP is not spending enough time with the client.
Option D shifts responsibility for managing the client's behavior to the nurse instead of helping the AP reflect on his or her perception of the situation.
Correct Answer is ["B","D","E"]
Explanation
The client with OCD may experience difficulty relaxing and often feels tense, anxious, and irritable. They may engage in rule-conscious behavior and exhibit perfectionist tendencies, as well as experience compulsive behaviors. These behaviors may be time-consuming and interfere with daily activities.
Option A is incorrect because irrational fear of certain objects is more indicative of a phobia than OCD.
Option C is incorrect because clients with OCD are usually aware of their compulsions and may even try to resist them.
Reasons why the other options are not correct answers:
Option A: Irrational fear of certain objects is more indicative of a phobia than OCD.
Option C: Clients with OCD are usually aware of their compulsions and may even try to resist them.
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