Nokea
An African American client comes to the clinic for a follow-up visit 2 months after starting enalapril for hypertension. Which client statement should be reported to the health care provider immediately?
- A. Is there anything I can take for my dry, hacking cough?
- B. My blood pressure this morning was 158/84 mm Hg.
- C. Sometimes I feel a little dizzy when I stand up.
- D. Will you look at my tongue? It feels thicker than normal.
Correct Answer: D
Rationale: A thicker tongue may indicate angioedema, a rare but life-threatening side effect of enalapril (an ACE inhibitor), requiring immediate reporting. A (dry cough) and C (dizziness) are common side effects that warrant monitoring but are less urgent. B indicates suboptimal blood pressure control, which requires follow-up but is not immediately life-threatening.
You may also like to solve these questions
The nurse has reinforced teaching with the parents of a 6-year-old client with chronic allergic rhinitis that is triggered by dust and pollen. Which of the following statements by the parents would indicate a correct understanding of the teaching? Select all that apply.
- A. We are planning to purchase an air purifier with a high-efficiency particulate air filter
- B. We will keep the windows open during warm weather to air out our house.
- C. We should place hypoallergenic covers on our child's mattress and pillow.
- D. We will clean our wood floors with a damp mop at least once a week
- E. We are planning to remove the carpet from our child's bedroom.
Correct Answer: A,C,D,E
Rationale: Correct choices reduce allergen exposure: HEPA filters remove dust/pollen, hypoallergenic covers prevent dust mite exposure, damp mopping reduces dust, and removing carpets eliminates allergen reservoirs. Keeping windows open increases pollen exposure, worsening symptoms.
The nurse is working to prevent falls in a restraint-free environment. Which of the following is inappropriate for the nurse to delegate to assistive personnel?
- A. Making sure the bed is in low position
- B. Making sure the bedside table is within reach of the client
- C. Assessing the safety needs of the client
- D. Monitoring client behavior for potential falls
Correct Answer: C
Rationale: Assessing safety needs requires nursing judgment, inappropriate for delegation to assistive personnel, unlike routine tasks like bed positioning.
The client has a cast applied following a fracture of the femur. The doctor tells the nurse to petal the cast. The nurse is aware that he intends for her to:
- A. Cut the cast down both sides.
- B. Cut a window in the cast.
- C. Cover the edges with cast batting.
- D. Cut the cast down one side.
Correct Answer: C
Rationale: Petaling a cast involves covering the rough edges with adhesive tape or cast batting to prevent skin irritation. Cutting the cast or creating a window is a different procedure.
Which actions by a nurse are reportable to the state board of nursing? Select all that apply.
- A. Administering hydromorphone without a prescription
- B. Being habitually tardy to work
- C. Documenting an intervention that was not performed
- D. Stealing narcotics
- E. Walking off duty in the middle of a shift
Correct Answer: A,C,D
Rationale: Administering medication without a prescription, falsifying documentation, and stealing narcotics are reportable to the state board. Tardiness and leaving a shift are not typically reportable.
Which of the following should the nurse teach the client to avoid when taking chlorpromazine HCL (Thorazine)?
- A. Direct sunlight
- B. Foods containing tyramine
- C. Foods fermented with yeast
- D. Canned citrus fruit drinks
Correct Answer: A
Rationale: Direct sunlight. Phenothiazines increase sensitivity to the sun, making clients especially susceptible to sunburn.