A nurse is assessing a client who is taking lisinopril. Which of the following findings should the nurse document in the client's medical record as an adverse effect?

Frequent, painless urination

Potassium 3.5 mEq/L (3.5 to 5 mEq/L)

Blood pressure 108/62 mm Hg

Frequent, nonproductive cough

Answer and Explanation

The Correct Answer is D

Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor commonly used to treat hypertension and heart failure. It works by inhibiting the conversion of angiotensin I to angiotensin II, leading to vasodilation and reduced blood pressure. While effective, ACE inhibitors are associated with characteristic adverse effects related to increased bradykinin levels. Nurses must monitor for both therapeutic effects and potential complications during therapy.

A. Frequent, painless urination is not a known adverse effect of lisinopril. Although blood pressure reduction may improve renal perfusion in some clients, lisinopril does not directly cause diuresis or urinary frequency. This finding is unrelated to ACE inhibitor therapy.

B. A potassium level of 3.5 mEq/L is at the lower limit of normal and does not represent an adverse effect of lisinopril. In fact, ACE inhibitors more commonly cause hyperkalemia due to decreased aldosterone secretion. Therefore, this finding is not consistent with expected medication effects.

C. A blood pressure of 108/62 mm Hg may reflect the intended therapeutic effect of lisinopril, which is to lower blood pressure. While hypotension can occur as an adverse effect, this value alone is not necessarily abnormal unless accompanied by symptoms such as dizziness or syncope.

D. A frequent, nonproductive cough is a well-known adverse effect of lisinopril caused by increased bradykinin levels in the respiratory tract. This persistent dry cough is a common reason for discontinuation of ACE inhibitors. It should be documented as an adverse effect and reported if it becomes bothersome or persistent.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

Incentive spirometry is a respiratory therapy technique used to promote lung expansion, prevent atelectasis, and improve oxygenation, especially after surgery or periods of immobility. It encourages sustained, deep inhalation to fully inflate the alveoli and enhance ventilation. Proper technique is essential for maximizing effectiveness and preventing postoperative pulmonary complications. Client education focuses on slow, controlled inhalation and regular use.

A. Placing the mouthpiece in the mouth and inhaling slowly is the correct technique for incentive spirometry. A slow, deep inhalation allows full expansion of the lungs and helps open collapsed alveoli, improving gas exchange. The client should aim to raise the indicator to the prescribed target level while maintaining a steady breath.

B. Removing the mouthpiece and exhaling quickly is incorrect because the primary goal of incentive spirometry is deep inspiration, not forceful exhalation. Rapid exhalation does not promote alveolar expansion and may reduce the effectiveness of the therapy. Controlled breathing in through the device is the key therapeutic action.

C. Using the incentive spirometer every 4 hours is less frequent than recommended for most clients. Typically, clients are encouraged to use it 5 to 10 times every hour while awake, especially in the postoperative period. Frequent use is necessary to maintain lung expansion and prevent complications.

D. Avoiding coughing during and after the session is incorrect because coughing is encouraged after using the incentive spirometer. Coughing helps mobilize and clear secretions that are loosened during deep breathing. This combination improves airway clearance and enhances lung function.

A. A client who is experiencing an opioid overdose B. A client who has aspiration pneumonia C. A client who has uncontrolled diabetes mellitus D. A client who is receiving continuous gastric suctioning

Correct Answer is D

Explanation

Acid–base balance is maintained through respiratory and metabolic processes that regulate hydrogen ion concentration in the body. Metabolic alkalosis occurs when there is a loss of hydrogen ions or an excess of bicarbonate, often related to gastrointestinal losses or prolonged acid depletion. Certain clinical conditions and treatments can predispose clients to this imbalance. Understanding these risk factors helps nurses anticipate and prevent complications.

A. Opioid overdose primarily causes respiratory depression, leading to hypoventilation and carbon dioxide retention. This results in respiratory acidosis rather than metabolic alkalosis. Therefore, this condition is not associated with the development of metabolic alkalosis.

B. Aspiration pneumonia can impair gas exchange and may lead to hypoventilation or hypoxemia. This condition is more likely to cause respiratory acidosis due to inadequate ventilation rather than a metabolic alkalosis. It is not a risk factor for increased bicarbonate levels.

C. Uncontrolled diabetes mellitus, especially in diabetic ketoacidosis, leads to metabolic acidosis due to accumulation of ketone bodies. This is the opposite of metabolic alkalosis and reflects excess acid production in the body rather than loss of hydrogen ions.

D. Continuous gastric suctioning removes gastric acid (hydrochloric acid) from the stomach, leading to a loss of hydrogen ions. This loss increases serum bicarbonate relative to acid levels, predisposing the client to metabolic alkalosis. This is a well-known cause of acid–base imbalance in clinical practice.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is assessing a client who is taking lisinopril. Which of the following findings should the nurse document in the client's medical record as an adverse effect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing education to a client who has a prescription for incentive spirometry. Which of the following instructions should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is caring for four clients. Which of the following clients is at risk for developing metabolic alkalosis?

Correct Answer is D

Explanation

A nurse is caring for a client who is receiving potassium chloride 40 mEq IV every 4 hr. Which of the following findings indicate the client is becoming hyperkalemic?

A nurse is providing discharge teaching to a client following a modified left radical mastectomy with breast expander. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is monitoring a client who has a head injury and is receiving mannitol 25% IV. The nurse should identify that which of the following is an adverse effect of the medication and should be reported to the provider?

A nurse in a provider's office is caring for a client who has total vision loss and is the handler of a service dog. Which of the following actions should the nurse take to show consideration for the client and the service animal?

A nurse is caring for a client whose partner has a terminal diagnosis. Which of the following statements made by the client indicates effective coping?

A nurse is caring for a client following a total knee arthroplasty. The client reports a pain level of 6 on a pain scale of 0 to 10. Which of the following interventions should the nurse take?

A nurse is providing instructions about foot care for a client who has peripheral arterial disease. The nurse should identify that which of the following statements by the client indicates an understanding of the teaching?