A client is prescribed lisinopril 20 mg PO daily for the treatment of hypertension. Which finding would alert the nurse that a side effect of the medication has occurred?
Blood pressure of 120/80 mmHg.
Serum potassium of 5.5 mEq/L.
Heart rate of 80 beats per minute.
Respiration rate of 16 breaths per minute.
The Correct Answer is B
Choice A Reason
A blood pressure of 120/80 mmHg is considered within the normal range and is an ideal target for most individuals being treated for hypertension. This finding would not typically alert the nurse to a side effect of lisinopril.
Choice B Reason
Serum potassium of 5.5 mEq/L is higher than the normal range, which is typically between 3.5 and 5.0 mEq/L. Lisinopril can cause hyperkalemia, which is an elevated level of potassium in the blood. This is a known side effect of lisinopril, especially in clients with renal impairment, as it inhibits the renin-angiotensin-aldosterone system and reduces potassium excretion.
Choice C Reason
A heart rate of 80 beats per minute is within the normal range for adults, which is typically 60-100 beats per minute at rest. This finding would not alert the nurse to a side effect of lisinopril.
Choice D Reason
A respiration rate of 16 breaths per minute is within the normal range for adults, which is typically 12-20 breaths per minute at rest. This finding would not alert the nurse to a side effect of lisinopril.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason
Thiamine, or vitamin B1, is essential for brain function and the metabolism of carbohydrates. In the context of high blood alcohol levels, thiamine is administered to prevent Wernicke's encephalopathy, a serious neurological disorder. This condition is often precipitated by a thiamine deficiency, which can be exacerbated by alcohol abuse. Alcohol consumption can impair thiamine absorption and utilization, leading to depleted stores. Wernicke's encephalopathy is characterized by symptoms such as confusion, ataxia, and ophthalmoplegia, and if left untreated, it can progress to Korsakoff syndrome, a chronic and debilitating condition.
Choice B Reason
While alcoholic hepatitis is a concern in individuals with excessive alcohol intake, thiamine is not specifically used to prevent this condition. Alcoholic hepatitis is inflammation of the liver due to alcohol abuse, and its prevention primarily involves abstinence from alcohol, nutritional support, and medical management of liver inflammation. Thiamine does not play a direct role in preventing liver inflammation but is crucial for overall nutritional replenishment in individuals with alcohol use disorder.
Choice C Reason
Rehydration is indeed important for clients with high blood alcohol levels; however, thiamine does not serve this purpose. Rehydration typically involves the administration of intravenous fluids to restore fluid balance and electrolytes. Thiamine is not a rehydrating agent but is given to prevent neurological complications associated with thiamine deficiency, which can be seen in individuals with chronic alcoholism.
Choice D Reason
Preventing pancreatitis is not the primary reason for administering thiamine in this scenario. Pancreatitis, an inflammation of the pancreas, can be associated with chronic alcohol abuse, but thiamine is not used as a preventative treatment for this condition. The management of pancreatitis involves addressing the underlying causes, supportive care, and sometimes hospitalization for more severe cases.
Correct Answer is C
Explanation
Choice A Reason
The continuous nature of the mucosa refers to the uninterrupted lining of the urinary tract, which provides a barrier against pathogens. However, this characteristic is not a significant factor in the increased susceptibility of women to cystitis. Both men and women have a continuous mucosal lining, and it does not account for the gender difference in infection rates.
Choice B Reason
High estrogen levels can influence the tissues of the urinary tract and may affect susceptibility to infections. However, the role of estrogen in the development of cystitis is not as direct or significant as anatomical differences. Estrogen levels vary throughout a woman's life and do not consistently correlate with cystitis risk.
Choice C Reason
Urethral proximity to the rectum is the most significant anatomical factor contributing to a woman's increased susceptibility to cystitis¹⁴. Women have a shorter urethra than men, and its close proximity to the anus allows bacteria from the bowel area to more easily enter the urinary tract and cause infections.
Choice D Reason
Inadequate fluid intake can lead to less frequent urination, which is a risk factor for cystitis because it reduces the natural flushing of bacteria from the urinary tract. However, this is a modifiable risk factor and does not inherently explain the higher incidence of cystitis in women compared to men.
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