A nurse assesses a client who is prescribed a medication that inhibits angiotensin I from converting into angiotensin II (angiotensin-converting enzyme (ACE) inhibitor). For which expected therapeutic effect should the nurse assess?

Blood pressure decrease from 180/72 mm Hg to 144/50 mm Hg

Daily weight increase from 55 kg to 57 kg

Heart rate decrease from 100 beats/min to 82 beats/min

Respiratory rate increase from 12 breaths/min to 15 breaths/min.

Answer and Explanation

The Correct Answer is A

A. Blood pressure decrease from 180/72 mm Hg to 144/50 mm Hg: ACE inhibitors block the conversion of angiotensin I to angiotensin II, which helps relax blood vessels and reduce blood pressure. This is the expected therapeutic effect of ACE inhibitors.

B. Daily weight increase from 55 kg to 57 kg: Increase in daily weight could indicate fluid retention, which is not the intended therapeutic effect of ACE inhibitors. These medications are often prescribed to reduce fluid retention, particularly in conditions like heart failure.

C. Heart rate decrease from 100 beats/min to 82 beats/min: ACE inhibitors primarily affect blood pressure regulation and fluid balance. A decrease in heart rate may occur with other types of medications (e.g., beta-blockers) but is not a primary effect of ACE inhibitors.

D. Respiratory rate increase from 12 breaths/min to 15 breaths/min: ACE inhibitors do not influence respiratory rate. Respiratory rate changes would be more related to respiratory conditions or other medications, not to the pharmacological effects of ACE inhibitors.

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Correct Answer is D

Explanation

A. 5.8 mEq/L: A potassium level of 5.8 mEq/L is still elevated, indicating that the sodium polystyrene sulfonate (Kayexalate) has not been fully effective in lowering the potassium to a normal range.

B. 5.5 mEq/L: While this level is slightly lower than 5.8 mEq/L, it still remains elevated above the normal range. It indicates some reduction in potassium, but it is not yet within the desired range.

C. 6.2 mEq/L: A potassium level of 6.2 mEq/L is critically high and reflects a lack of effectiveness of the Kayexalate treatment. This level is very high suggesting that the medication has not worked.

D. 4.9 mEq/L: A potassium level of 4.9 mEq/L is within the normal range (3.5-5.0 mEq/L). This indicates that the sodium polystyrene sulfonate (Kayexalate) has been effective in lowering the potassium to a safe and normal level.

A. Instruct the patient to eat a diet high in potassium B. Monitor cardiac status C. Administer Spironolactone D. Administer an IV of 0.9% NS with potassium added

Correct Answer is B

Explanation

A. Instruct the patient to eat a diet high in potassium: This would be inappropriate for a patient with hyperkalemia, as high potassium intake could worsen the condition. Hyperkalemia requires a reduction in potassium intake, not an increase.

B. Monitor cardiac status: Hyperkalemia can cause dangerous cardiac arrhythmias and other heart-related issues. Therefore, it is critical to monitor the cardiac status of a patient with hyperkalemia to detect any changes that could indicate a life-threatening condition, such as arrhythmias.

C. Administer Spironolactone: Spironolactone is a potassium-sparing diuretic, which can increase potassium levels. Administering it in the case of hyperkalemia could worsen the condition, making this an inappropriate intervention.

D. Administer an IV of 0.9% NS with potassium added: Administering an IV solution with added potassium would worsen hyperkalemia, as it would increase potassium levels further. In cases of hyperkalemia, it's important to avoid additional potassium administration.

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A nurse assesses a client who is prescribed a medication that inhibits angiotensin I from converting into angiotensin II (angiotensin-converting enzyme (ACE) inhibitor). For which expected therapeutic effect should the nurse assess?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with a critically high potassium level (Normal is 3.5-5.0 mEq/L). The client has received sodium polystyrene sulfonate (Kayexalate). The nurse determines the medication's effectiveness if the client's repeat serum potassium level is:

Correct Answer is D

Explanation

A nursing intervention for Hyperkalemia is?

Correct Answer is B

Explanation

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