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 C

Explanation

A. Instruct the client to report bleeding: While important, assessing for bleeding is not the immediate priority. Minor blood-tinged sputum can be expected, but significant bleeding should be reported. Ensuring airway protection comes first.

B. Inform the client they might experience a low-grade fever: A mild fever may occur within the first 24 hours after bronchoscopy due to irritation, but addressing airway safety and aspiration risk takes precedence.

C. Check the client's gag reflex: The gag reflex must return before offering oral intake to prevent aspiration. The local anesthetic used for the procedure can suppress the reflex, increasing the risk of aspiration if the client drinks or eats too soon.

D. Provide the client with sips of water: Fluids should not be given until the gag reflex has returned. Providing water too soon could result in aspiration, leading to complications such as pneumonia.

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}

Explanation

Myocardial infarction: The rising troponin levels (Troponin T increasing from 0.08 ng/mL to 0.2 ng/mL and Troponin I rising from 0.01 ng/mL to 0.1 ng/mL) indicate myocardial injury. Persistent chest tightness, shortness of breath, diaphoresis, and anxiety suggest ongoing ischemia. The lack of complete pain relief after nitroglycerin further supports myocardial infarction rather than stable angina.
Pulmonary embolism: Shortness of breath is a symptom of pulmonary embolism, but the absence of acute hypoxia, pleuritic chest pain, or significant coagulation abnormalities makes this less likely. The client's symptoms and laboratory findings more strongly support a cardiac etiology.
Bleeding: While thrombolytic therapy increases bleeding risk, the aPTT (32 seconds) and platelet count (350,000/mm³) are within normal limits. There are no reported signs of active bleeding, such as hypotension, bruising, or hematuria, making this a less relevant immediate concern.
Shortness of breath: Often present in myocardial infarction due to decreased cardiac output and pulmonary congestion. The combination of chest pain, diaphoresis, and dyspnea suggests worsening ischemia rather than a primary pulmonary process. However, it is a nonspecific symptom that can also indicate pulmonary embolism or respiratory distress.
aPTT levels: Normal at 32 seconds (reference: 30–40 seconds), which suggests no immediate risk of abnormal clotting or excessive anticoagulation. This finding does not directly indicate myocardial infarction but is important in monitoring bleeding risk with thrombolytic therapy. A significantly elevated aPTT could raise concern for hemorrhagic complications.
Elevated troponin levels: A highly specific marker for myocardial injury. The rise in Troponin T and Troponin I over time confirms myocardial damage, distinguishing acute coronary syndrome from stable angina. This trend is critical in diagnosing myocardial infarction, as troponin elevation correlates with the extent of cardiac muscle injury.

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