A client with a history of heart failure and hypertension is in the clinic for a follow-up visit.
The client is on lisinopril and warfarin.
The client reports a new-onset cough.
What action by the nurse is most appropriate?
Assess the client's lung sounds and oxygenation.
Instruct the client on another antihypertensive.
Obtain a set of vital signs and document them.
Remind the client that a cough is a side effect of lisinopril.
The Correct Answer is A
Choice A rationale
While a cough is a known side effect of lisinopril due to bradykinin accumulation, a new-onset cough in a client with heart failure and hypertension could also signal worsening heart failure, particularly pulmonary edema. Assessing lung sounds for crackles and monitoring oxygenation is paramount to differentiate between these two distinct etiologies and guide appropriate intervention.
Choice B rationale
Changing antihypertensives is a medical decision made by the provider. The nurse's role is to assess the client's symptoms and provide objective data to the provider. Switching medications without a thorough assessment could be premature and might delay the diagnosis of a more serious condition like decompensated heart failure.
Choice C rationale
Obtaining vital signs is a fundamental nursing action, but it is not the most appropriate initial action in this specific clinical scenario. The report of a new cough in a client with heart failure necessitates a targeted assessment of the respiratory system, including auscultating lung sounds and evaluating for signs of hypoxemia, to rule out a life-threatening complication.
Choice D rationale
While a cough is a known side effect of lisinopril, dismissing the symptom could be dangerous. The cough may not be benign; it could be an early sign of pulmonary congestion from heart failure. The nurse must perform a comprehensive assessment to ensure the client's safety and to avoid misattributing a serious finding to a common medication side effect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
Choice A rationale
Regular assessment for bleeding is critical because heparin inhibits the coagulation cascade by enhancing antithrombin III, which inactivates thrombin and factor Xa. This increases the risk of hemorrhage, so the nurse must monitor for signs like petechiae, ecchymosis, hematuria, or GI bleeding to prevent serious complications. Platelets should be maintained above 100,000.
Choice B rationale
The activated partial thromboplastin time (aPTT) measures the time it takes for a fibrin clot to form via the intrinsic and common pathways of the coagulation cascade. Heparin therapy is monitored by the aPTT, with a therapeutic range typically 1.5 to 2.5 times the client’s baseline or control value, usually 45-75 seconds.
Choice C rationale
Stopping an IV heparin infusion for an aPTT above baseline is not always the correct action, as the therapeutic range is purposefully elevated. The aPTT should be 1.5 to 2.5 times the control value. An aPTT above this therapeutic range warrants holding the dose or adjusting the rate according to established hospital protocols and provider orders.
Choice D rationale
Using an IV pump is essential for heparin infusion to ensure precise and consistent administration. Heparin is a high-alert medication with a narrow therapeutic index. An IV pump prevents boluses and ensures the client receives the exact prescribed dose over time, minimizing the risk of subtherapeutic levels or overdose.
Choice E rationale
Daily weighing is crucial for monitoring fluid balance and detecting fluid shifts, which can indicate internal bleeding, a significant risk with heparin. Using the same scale at the same time each day, with the client wearing similar clothing, ensures accurate and comparable measurements, providing a reliable trend of the client’s weight.
Correct Answer is C
Explanation
Choice A rationale
Tazarotene, a retinoid, increases photosensitivity by thinning the stratum corneum, the skin's outermost layer. This reduces the protective barrier against ultraviolet (UV) radiation, making the skin more susceptible to sunburn and UV-induced DNA damage. Patients must be educated to use sun protection, but it is not the most critical question.
Choice B rationale
While a history of skin cancer can influence dermatological treatment plans, it is not the primary contraindication for tazarotene. Tazarotene is an analog of vitamin A, and its mechanism involves regulating cell proliferation and differentiation, which is not directly related to a personal or family history of skin cancer.
Choice C rationale
Tazarotene is a potent teratogen, meaning it can cause severe congenital malformations if taken during pregnancy. This teratogenic risk necessitates that all female patients of child-bearing potential use reliable contraception to prevent pregnancy. A pregnancy test is also required before initiation of therapy.
Choice D rationale
While some medications interact with alcohol, tazarotene is a topical retinoid primarily metabolized in the liver to its active form, tazarotenic acid. There is no significant systemic absorption or direct interaction with alcohol consumption that would cause a major adverse effect, making it a less critical question than contraception.
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