Nokea
A client has been taking lisinopril for 3 months. The client reports to the nurse a persistent dry cough that began about 1 month ago. The nurse interprets that the most likely reason for the client's complaint is what?
- A. Neutropenia as a result of therapy
- B. An expected side effect of therapy
- C. Undiagnosed existence of heart failure
- D. A concurrent upper respiratory infection
Correct Answer: B
Rationale: A frequent side effect of therapy with any of the angiotensin-converting enzyme (ACE) inhibitors, such as lisinopril, is the appearance of a persistent, dry cough. The cough generally does not improve while the client is taking the medication. Clients are advised to notify the primary health care provider if the cough becomes very troublesome to them. The other options are incorrect interpretations.
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A client with angina shows the nurse her nitroglycerin (Nitrostat) that she carries in a plastic bag in her pocket. The nurse instructs the client that nitroglycerin should be kept in:
- A. The refrigerator.
- B. A cool, moist place.
- C. A dark container to shield from light.
- D. A plastic bag where it is readily available.
Correct Answer: C
Rationale: Nitroglycerin is sensitive to light and heat, which can degrade its potency. Storing it in a dark container protects it from light exposure, ensuring effectiveness.
The nurse is caring for a client with a history of burns covering 30% of the body. Which of the following interventions should be prioritized?
- A. Administer I.V. fluids.
- B. Apply antibiotic cream.
- C. Monitor for infection.
- D. Administer analgesics.
Correct Answer: A
Rationale: I.V. fluids are the priority to replace fluid loss and prevent hypovolemic shock in burn injuries.
A client admitted in an acute psychotic state says that she hears terrible voices in the head and thinks her neighbor is out to get her. Which of the following is the nurse's best response?
- A. What has your neighbor been doing that bothers you?'
- B. How long have you been hearing these terrible voices?'
- C. I won't let your neighbor visit, so you'll be safe.'
- D. What exactly are these terrible voices saying to you?'
Correct Answer: D
Rationale: Asking about the content of the voices helps assess the nature of the hallucinations and potential risks, guiding therapeutic intervention.
A client with a fractured femur is in skeletal traction. The nurse should assess for which of the following complications?
- A. Fat embolism.
- B. Hypovolemia.
- C. Osteomyelitis.
- D. Pressure ulcers.
Correct Answer: A, D
Rationale: Fat embolism is a risk with long bone fractures, and pressure ulcers can develop due to immobility in traction.
The nurse is conducting walking rounds and observes the client (see figure). The nurse should do which of the following?
- A. Loosen the bed restraints so the client can sit up.
- B. Raise the side rails to full upright position.
- C. Assess the client to determine why she wants to sit up.
- D. Elevate the head of the bed.
Correct Answer: C
Rationale: The nurse should fi rst determine why the client wants to sit up, and then, if needed delegate someone to assist the client. Loosening the restraints will not keep the client safe in bed. Raising theside rails and elevating the head of the bed do not address the client’s needs.