Nokea
A client has a nursing diagnosis of Activity Intolerance related to fatigue and weakness. Which of the following would be appropriate for the nurse to include in the client's plan of care?
- A. Encouraging ambulation as tolerated
- B. Maintaining bed rest as much as possible
- C. Mandating the use of assistive devices
- D. Encouraging activities early in the morning when fatigue is less
- E. Promoting rest periods throughout the day as necessary
Correct Answer: A,E
Rationale: The client is encouraged to walk and ambulate as he or she can tolerate. Assistive devices may be used if needed, but these should not be mandated for use. The client can gradually increase tolerance by increasing the daily amount of activity. Planning rest periods according to the individual's tolerance is appropriate. Rest can take many forms, such as sitting in a chair, napping, watching television, or sitting with legs elevated.
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A client is prescribed atenolol. After administering the drug, the nurse would be alert for which of the following? Select all that apply.
- A. Cough
- B. Hyperkalemia
- C. Bradycardia
- D. Dizziness
- E. Constipation
Correct Answer: C,D
Rationale: Common adverse reactions seen with atenolol, a beta-adrenergic blocker, include bradycardia, dizziness, fatigue, weakness, hypotension, nausea, vomiting, diarrhea, and nervousness. Cough is associated with ACE inhibitors. Hyperkalemia is associated with eplerenone and aliskiren. Constipation is not a common adverse reaction with atenolol.
A client is prescribed clonidine as a transdermal patch. After instructing the client about this drug, the nurse determines that the teaching was successful when the client states that the patch should remain in place for how long?
- A. 24 hours
- B. 3 days
- C. 7 days
- D. 2 weeks
Correct Answer: C
Rationale: The nurse should ensure that the transdermal patch is intact for a period of 1 week. A clonidine transdermal patch should be applied to a hairless area over the torso for 1 week. If the patch loosens before 7 days, it has to be reinforced. The nurse has to mark the date of placement and the date of removal of the patch on the surface of the patch.
After teaching a group of nursing students about antihypertensive drugs, the instructor determines a need for additional teaching when the students identify which of the following as an angiotensin-converting enzyme inhibitor?
- A. Pindolol
- B. Benazepril
- C. Quinapril
- D. Enalapril
Correct Answer: A
Rationale: Pindolol is a beta-adrenergic blocker. Benazepril, quinapril, and enalapril are ACEIs.
Before administering an antihypertensive, the nurse should complete which of the following assessments? Select all that apply.
- A. Pulse rate on both arms
- B. Pulse rate on one arm
- C. Blood pressure in the sitting position
- D. Blood pressure on both arms
- E. Blood pressure on one arm
Correct Answer: A,C,D
Rationale: Preadministration assessment for antihypertensives should include blood pressure and pulse rate on both arms with the client in standing, sitting, and lying positions.
A client who is prescribed losartan for hypertension has stopped taking the drug immediately after experiencing adverse reactions. The nurse would be alert for which of the following due to abrupt discontinuation?
- A. Breathing difficulty
- B. Rebound hypertension
- C. Orthostatic hypotension
- D. Anginal attacks
Correct Answer: B
Rationale: Rebound hypertension will occur in clients when antihypertensives are abruptly discontinued. In rebound hypertension, there is a sudden rise in blood pressure when the antihypertensives are withheld. Orthostatic hypotension, anginal attacks, and breathing difficulty are the adverse reactions associated with antihypertensive drug usage and may not occur on stopping the drug.