A nurse is assessing a client who is taking losartan. Which of the following findings should the nurse identify as an adverse effect of this medication?

Hypertension

Dizziness

Double vision

Hyperactivity

Answer and Explanation

The Correct Answer is B

A. Losartan is an angiotensin II receptor blocker (ARB) used to treat hypertension, so it does not cause hypertension. Instead, it lowers blood pressure.
B. Dizziness is a common adverse effect of losartan due to its blood pressure-lowering effects, which can lead to orthostatic hypotension.
C. Double vision is not a known adverse effect of losartan.
D. Losartan does not cause hyperactivity; it is more likely to cause fatigue or weakness.

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Correct Answer is A

Explanation

A. Ensure 2 cm (0.8 in) of water is in the water seal chamber. This is correct because maintaining the correct water level in the water seal chamber is essential for proper functioning of the chest tube system, as it prevents air from entering the pleural space.
B. Check the patency of the tubing every 2 hr. This is incorrect because continuous monitoring is required, and patency should be ensured at all times, not just at set intervals. However, frequent assessments are important.
C. Keep the drainage system above the level of the client's chest. This is incorrect because the drainage system should be kept below chest level to allow gravity drainage and prevent backflow into the pleural space.
D. Empty the collection chamber every 8 hr. This is incorrect because the collection chamber should only be emptied when full, following facility protocol, to maintain an accurate record of drainage output.

A. Initiate an IV infusion of lactated Ringer's. B. Place the client in a left lateral position. C. Monitor blood pressure every hour. D. Maintain continuous monitoring of the FHR.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

Anticipated Interventions:

Initiate an IV infusion of lactated Ringer's
Place the client in a left lateral position
Maintain continuous monitoring of the FHR

Contraindicated Intervention:

Monitor blood pressure every hour

Rationale:

Initiate an IV infusion of lactated Ringer’s: Hydration is important for labor progression and maternal hemodynamic stability, especially considering the client has a history of chronic hypertension and gestational diabetes.
Place the client in a left lateral position: This improves uteroplacental perfusion, helping to optimize fetal oxygenation.
Maintain continuous monitoring of the FHR: The presence of meconium-stained amniotic fluid and an elevated FHR (165/min) suggests potential fetal distress, warranting continuous fetal monitoring.
Monitor blood pressure every hour (Contraindicated): The client has chronic hypertension and gestational diabetes, both of which increase the risk for complications like preeclampsia and fetal distress. More frequent BP monitoring (e.g., every 15-30 minutes) is necessary to detect any abnormalities early.

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A nurse is assessing a client who is taking losartan. Which of the following findings should the nurse identify as an adverse effect of this medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a three-chamber chest tube system. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse in an antepartum unit is caring for a client. Exhibits For each potential intervention, click to specify if the intervention is anticipated or contraindicated for the client.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

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