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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

0745.. Regular insulin has an onset of action of 30 to 60 minutes, a peak effect of 2 to 4 hours, and a duration of action of 6 to 8 hours. Therefore, the patient should receive breakfast within 30 minutes of receiving the insulin injection to prevent hypoglycemia.

Choice A. 0720 is incorrect because it is too soon after the injection and the insulin may not have reached its onset of action yet.

Choice B. 0815 is incorrect because it is too late after the injection and the insulin may have reached its peak effect by then, increasing the risk of hypoglycemia.

Choice D. 0730. is incorrect because it is less than 30 minutes after the injection and the insulin may be approaching its peak effect.

A. Identify support groups in the community for long-term treatment. B. Assist the client to identify negative effects of chemical dependency. C. Determine the presence and degree of suicidal risk. D. Refer client to mental health care provider for evaluation and treatment.

Correct Answer is C

Explanation

The nurse should determine the presence and degree of suicidal risk when caring for a client who has a depressive disorder, is in alcohol withdrawal, and reports a recent job loss. This intervention is the priority because the client is at increased risk of suicidal ideation or behavior due to the combination of depression, alcohol withdrawal, and recent job loss. Identifying support groups in the community for long-term treatment.

choice A and referring the client to a mental health care provider for evaluation and treatment.

choice D are important interventions but are not the priority at this time. Assisting the client to identify the negative effects of chemical dependency.

choice B may be necessary but does not address the priority concern of suicidal risk.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient with diabetes mellitus who is prescribed regular insulin via a sliding scale. After administering the correct dose at 0715, by which of the following times should the nurse ensure the patient receives breakfast?

Correct Answer is C

Explanation

A nurse is caring for a client who has depressive disorder, is in alcohol withdrawal, and reports a recent job loss. Which of the following should be the priority nursing intervention?

Correct Answer is C

Explanation

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