After administering lisinopril, an angiotensin-converting enzyme (ACE) inhibitor, it is most important for the nurse to monitor which assessment finding?

Serum potassium and skin turgor.

Eosinophil count and constipation.

Blood pressure and risk for falls.

Heart rate and reports of nausea.

Answer and Explanation

The Correct Answer is C

Choice A reason: Monitoring serum potassium is relevant, as lisinopril can cause hyperkalemia by reducing aldosterone, impairing potassium excretion. Skin turgor, however, assesses hydration, not ACE inhibitor effects. Blood pressure monitoring is more critical, as lisinopril lowers blood pressure via vasodilation, risking hypotension and falls, especially in elderly clients.

Choice B reason: Eosinophil count and constipation are unrelated to lisinopril’s effects. Elevated eosinophils may suggest allergies, but this is rare with ACE inhibitors. Constipation is not a common side effect. Lisinopril’s primary action is renin-angiotensin inhibition, making blood pressure and fall risk monitoring more urgent to prevent hypotensive complications.

Choice C reason: Lisinopril reduces angiotensin II, promoting vasodilation and lowering blood pressure. Monitoring blood pressure detects hypotension, which increases fall risk, particularly in older adults, due to dizziness or orthostatic changes. This directly assesses the drug’s cardiovascular effects, ensuring safety by preventing falls or syncope, making it the priority assessment.

Choice D reason: Heart rate and nausea are not primary lisinopril concerns. Tachycardia may occur secondary to hypotension, and nausea is rare. The drug’s main effect is blood pressure reduction via ACE inhibition, necessitating monitoring for hypotension and fall risk to ensure patient safety, as these are more immediate and significant pharmacological effects.

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Correct Answer is A

Explanation

Choice A reason: Topical corticosteroids reduce eczema’s inflammation by inhibiting cytokines, alleviating antecubital vesicles. Heat lamps dry skin, worsening irritation and cracking. Encouraging steroids addresses the inflammatory pathophysiology, promoting healing, making this the most effective response for managing eczema and correcting harmful self-treatment.

Choice B reason: Chemical debridement is for necrotic tissue, not eczema’s inflammatory vesicles. Heat lamps exacerbate dryness, but debridement does not address immune-mediated inflammation. Corticosteroids target the cytokine-driven process, making debridement inappropriate for eczema’s pathophysiology, which requires anti-inflammatory treatment.

Choice C reason: Restricting heat to 15–20 minutes does not mitigate harm, as heat dries eczema lesions, disrupting the skin barrier and increasing infection risk. Corticosteroids reduce inflammation, addressing vesicles. Heat worsens epidermal damage, making this response ineffective compared to targeting the inflammatory cause.

Choice D reason: A sling for arm elevation is irrelevant for localized eczema, an inflammatory dermatitis, not edema requiring elevation. Heat lamps aggravate dryness, and corticosteroids treat inflammation, addressing immune-mediated pathology more effectively than positional changes, which do not impact eczema’s skin symptoms.

A. Difficulty swallowing secretions. B. Fever 101.0°F (38.3°C). C. Cries often when nursing. D. Barking cough, worse at night.

Correct Answer is A

Explanation

Choice A reason: Difficulty swallowing secretions in croup signals severe airway narrowing from subglottic edema, often parainfluenza-induced. This risks stridor and obstruction, leading to respiratory distress or hypoxia. It requires urgent evaluation for corticosteroids or epinephrine, prioritizing airway patency over less critical symptoms, preventing life-threatening complications.

Choice B reason: Fever of 101.0°F (38.3°C) is common in croup, indicating viral infection, but less urgent than swallowing difficulty, which suggests critical airway compromise. Fever is managed with antipyretics, but severe edema risking obstruction necessitates immediate intervention, making this a lower priority concern.

Choice C reason: Crying when nursing may reflect croup’s sore throat or breathing difficulty but is less specific than swallowing difficulty, indicating severe airway narrowing. Crying does not directly signal life-threatening obstruction, making it less urgent than symptoms of significant subglottic inflammation requiring medical attention.

Choice D reason: Barking cough, worse at night, is typical in croup from subglottic inflammation but managed with supportive care or steroids. Difficulty swallowing secretions indicates severe airway compromise, risking obstruction, requiring urgent intervention over a cough, which is an expected, less critical symptom.

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After administering lisinopril, an angiotensin-converting enzyme (ACE) inhibitor, it is most important for the nurse to monitor which assessment finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client newly diagnosed with eczema tells the clinic nurse of using a heat lamp to dry the fluid-filled blisters localized in the left antecubital area. How should the nurse respond?

Correct Answer is A

Explanation

When advising a new mother in caring for a child with croup, which symptom should be a priority concern to the telephone triage nurse?

Correct Answer is A

Explanation

The nurse is teaching a client with newly diagnosed glaucoma about the condition. Which statement by the client indicates a need for further teaching?

During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms?

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