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 B
Explanation
Choice A rationale
This meal provides carbohydrates and fiber, but it lacks sufficient protein, which is essential for tissue repair and collagen synthesis. Protein intake is crucial for wound healing. A green salad provides vitamins, but the overall meal composition is not optimal for providing the building blocks necessary for skin and tissue regeneration.
Choice B rationale
This dietary choice is excellent for promoting wound healing. Chicken breast provides a high-quality source of protein, which is essential for rebuilding damaged tissue and forming new collagen. Broccoli provides vitamin C, a co-factor in collagen synthesis, while a baked potato offers carbohydrates for energy to fuel the healing process.
Choice C rationale
Vegetable lasagna and green salad provide some vitamins and nutrients, but they are often lower in protein than meat-based options, especially if the lasagna filling is not fortified with high-protein ingredients like cottage cheese. Protein is a critical macronutrient for tissue repair, and the lack of a concentrated source makes this choice suboptimal.
Choice D rationale
This meal is low in essential nutrients. While a hamburger provides some protein, it is often high in saturated fat. The fruit cup and cookie provide simple sugars, which can lead to inflammation and have minimal nutritional value for wound healing. The diet pop offers no nutritional benefit and may contain artificial ingredients that are not beneficial.
Correct Answer is A
Explanation
Choice A rationale
Isotretinoin is a highly effective medication for severe acne, but it is a potent human teratogen. It can cause severe birth defects, miscarriage, and premature birth if a patient becomes pregnant while taking it. The iPLEDGE program mandates two forms of contraception and monthly pregnancy tests for all female patients.
Choice B rationale
The dose of isotretinoin is carefully titrated based on the patient's weight and response to therapy. Increasing the dose without a physician's order is extremely dangerous and can lead to severe side effects such as cheilitis, xerosis, and potential liver damage. Doses are not to be altered by the patient.
Choice C rationale
There is no credible scientific evidence that the intake of specific foods like chocolate, cola, or peanuts causes or exacerbates acne. This is a common misconception. Acne pathogenesis involves sebum production, follicular hyperkeratinization, and bacterial proliferation, not dietary intake of these items.
Choice D rationale
Isotretinoin increases the skin's sensitivity to sunlight and UV radiation, a condition known as photosensitivity. This effect is due to the drug's impact on skin cell turnover and thinning of the stratum corneum. Patients are advised to limit sun exposure and use broad-spectrum sunscreens to prevent severe sunburn.
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