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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Prevent the client from harming herself or others. Withdrawal from alcohol can lead to autonomic hyperactivity and is most concerning when it involves seizures, deliriums tremens, and hallucinations which can be potentially life-threatening. Therefore, the nurse's priority when caring for a client experiencing alcohol withdrawal is to prevent harm to the client by implementing seizure precautions and monitoring the client's vital signs.
Choice A, identifying the use of defense mechanisms, is an important aspect of treatment but can be addressed later.
Choice C, supporting the client's coping skills, is not a priority intervention.
Correct Answer is D
Explanation
The client is easily startled by loud voices. Clients with posttraumatic stress disorder (PTSD) may exhibit hyperarousal symptoms, including exaggerated startle responses and hypervigilance. The client talking constantly about the traumatic experience is a possible finding in PTSD but not specific. The client is constantly drowsy and sleeping 11-12 hours daily is more associated with depression than PTSD. While the client may have satisfying personal relationships, it does not address the question of what finding to expect with PTSD, making choice C incorrect.
Reasons why the other choices are not answers:
Choice A, the client talking constantly about the traumatic experience, is a possible symptom of PTSD, but it is not specific to the disorder and may also indicate other disorders.
Choice B, the client being constantly drowsy and sleeping 11-12 hours daily, is more indicative of depression than PTSD and also does not address the question of finding expected with PTSD.
Choice C, the client reports satisfying personal relationships with family and close friends, does not address what finding is expected with PTSD, making it an incorrect answer.
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