Nokea
The nurse should notify the primary health care provider when which of the following occur while a client is receiving an antihypertensive? Select all that apply.
- A. Weight gain of 2 lb or more per day
- B. Headache
- C. Edema
- D. Insomnia
- E. Sedation
Correct Answer: A,C
Rationale: The nurse should notify the primary health care provider if a client has a weight gain of 2 lb or more per day or edema of the hands, fingers, feet, legs, or sacral area.
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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.
When providing care to a client with hypertension who is receiving antihypertensive therapy, which assessment would be the highest priority?
- A. Pain rating
- B. Blood pressure monitoring
- C. Weight measurement
- D. Complaints of adverse reactions
Correct Answer: B
Rationale: Although assessing for pain, measuring weight, and assessing for complaints of adverse reactions are important, monitoring the client's blood pressure would have the highest priority because the drug therapy regimen may need to be adjusted or changed if the client's response is inadequate.
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.
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.
Angioedema is a potentially life-threatening medical condition that is associated with some classes of antihypertensive medications. The nurse suspects that a client is experiencing angioedema based on which assessment finding? Select all that apply.
- A. Heart rate above 100 beats per minute
- B. Fever greater than 100°C
- C. Swelling of the face
- D. Swelling of the throat
- E. Blood pressure above 170/100 mm Hg
Correct Answer: C,D
Rationale: Angioedema presents with swelling of the face, lips, throat, or extremities.