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?

Blood pressure 108/62 mm Hg

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

Frequent, nonproductive cough

Frequent, painless urination

Answer and Explanation

The Correct Answer is C

A. Blood pressure 108/62 mm Hg: Lisinopril is an antihypertensive, and a systolic BP above 90 mm Hg is typically not considered an adverse effect. Hypotension can occur but is more concerning if it results in symptoms such as dizziness or syncope.

B. Potassium 3.5 mEq/L (3.5 to 5 mEq/L): Lisinopril can cause hyperkalemia, but a potassium level of 3.5 mEq/L is within the normal range. Monitoring potassium levels is essential, but this finding does not indicate an adverse effect.

C. Frequent, nonproductive cough: A dry, persistent cough is a common adverse effect of lisinopril due to the accumulation of bradykinin. It often does not resolve until the medication is discontinued or switched to an alternative, such as an angiotensin receptor blocker (ARB).

D. Frequent, painless urination: Lisinopril does not typically cause increased urination. While it affects renal function, it is more likely to lead to hyperkalemia or reduced glomerular filtration rate in susceptible individuals.

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Correct Answer is D

Explanation

A. Place the client in a negative pressure room: Negative pressure rooms are used for airborne precautions, such as tuberculosis, but are not required for internal brachytherapy. Clients receiving internal radiation require a private room with appropriate shielding to limit radiation exposure.

B. Dispose of the radioactive source in the client's trash can: Radioactive sources should never be discarded in regular trash. If dislodged, the source must be handled properly using protective equipment and disposed of in a designated lead container to prevent radiation exposure.

C. Limit each visitor to 1 hr per day: Visitors should be limited to 30 minutes per day and should maintain a distance of at least 6 feet from the client. This minimizes radiation exposure to family members and healthcare providers.

D. Use long-handled forceps if the radioactive source is dislodged: If the internal radiation source becomes dislodged, it should never be touched directly. Long-handled forceps should be used to carefully place the source in a lead-lined container to protect against radiation exposure.

A. "I should expect to have swelling in my feet." B. "The iron supplement might cause my stools to be black." C. "The iron supplement might cause ringing in my ears." D. "I should increase green leafy vegetables in my diet." E. "I will take my iron supplement 1 hour before a meal."

Correct Answer is ["B","D","E"]

Explanation

"The iron supplement might cause my stools to be black.": This statement is correct as one of the common side effects of iron supplementation is darkening of the stools. This occurs due to the unabsorbed iron and is generally harmless, but clients should be educated about this to avoid confusion with gastrointestinal bleeding.
"I should increase green leafy vegetables in my diet.": Green leafy vegetables are excellent sources of iron, particularly non-heme iron, which can help improve the client's iron levels. Encouraging a diet rich in iron-rich foods is essential for effective management of iron deficiency anemia, especially for clients on a vegan diet.
"I will take my iron supplement 1 hour before a meal.": Taking iron supplements on an empty stomach enhances absorption. Clients should be instructed to take the supplement ideally 1 hour before meals or 2 hours after meals for optimal efficacy, unless gastrointestinal discomfort occurs.

"I should expect to have swelling in my feet.": This statement is not appropriate. Swelling in the feet may indicate fluid retention or other medical issues that should be reported. It is not a typical or expected side effect of iron supplementation or iron deficiency anemia.
"The iron supplement might cause ringing in my ears.": Ringing in the ears (tinnitus) is not a common side effect of iron supplements. If a client experiences this symptom, it may be related to other factors or medications and should be investigated further.

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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

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Correct Answer is ["B","D","E"]

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