After administering lisinopril, an angiotensin-converting enzyme (ACE) inhibitor, it is most important for the nurse to monitor which assessment finding?

Serum potassium and skin turgor.

Eosinophil count and constipation.

Blood pressure and risk for falls.

Heart rate and reports of nausea.

Answer and Explanation

The Correct Answer is C

Choice A reason: Monitoring serum potassium is relevant, as lisinopril can cause hyperkalemia by reducing aldosterone, impairing potassium excretion. Skin turgor, however, assesses hydration, not ACE inhibitor effects. Blood pressure monitoring is more critical, as lisinopril lowers blood pressure via vasodilation, risking hypotension and falls, especially in elderly clients.

Choice B reason: Eosinophil count and constipation are unrelated to lisinopril’s effects. Elevated eosinophils may suggest allergies, but this is rare with ACE inhibitors. Constipation is not a common side effect. Lisinopril’s primary action is renin-angiotensin inhibition, making blood pressure and fall risk monitoring more urgent to prevent hypotensive complications.

Choice C reason: Lisinopril reduces angiotensin II, promoting vasodilation and lowering blood pressure. Monitoring blood pressure detects hypotension, which increases fall risk, particularly in older adults, due to dizziness or orthostatic changes. This directly assesses the drug’s cardiovascular effects, ensuring safety by preventing falls or syncope, making it the priority assessment.

Choice D reason: Heart rate and nausea are not primary lisinopril concerns. Tachycardia may occur secondary to hypotension, and nausea is rare. The drug’s main effect is blood pressure reduction via ACE inhibition, necessitating monitoring for hypotension and fall risk to ensure patient safety, as these are more immediate and significant pharmacological effects.

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Correct Answer is D

Explanation

Choice A reason: Acetaminophen reduces pain but is secondary to preventing infection and bleeding with petrolatum dressings. Dressings are the immediate post-circumcision priority to protect the surgical site, per circumcision care and infection control protocols in neonatal nursing practice.

Choice B reason: Wrapping in blankets maintains warmth but does not address the surgical site’s immediate needs. Petrolatum dressings prevent infection and adhesion, critical post-circumcision. Warmth is secondary, per circumcision care and neonatal thermoregulation standards in nursing practice.

Choice C reason: Offering a glucose-dipped pacifier soothes but does not protect the circumcision site from infection or bleeding. Petrolatum dressings are the priority to ensure healing and comfort, per circumcision care and postoperative pain management standards in neonatal nursing practice.

Choice D reason: Applying petrolatum gauze dressings prevents infection, promotes healing, and reduces adhesion of the circumcision site to diapers. This is the priority intervention to protect the surgical wound, per evidence-based circumcision care and infection control protocols in neonatal nursing practice.

A. Take the medication on an empty stomach. B. Report any signs of gastrointestinal bleeding. C. Wear a high intensity sunblock when outside. D. Monitor blood pressure frequently.

Correct Answer is B

Explanation

Choice A reason: Taking ibuprofen on an empty stomach increases gastrointestinal irritation, as NSAIDs inhibit prostaglandins, reducing gastric mucus protection. This risks gastritis or ulcers. Taking it with food minimizes irritation, making this instruction incorrect and potentially harmful for clients managing chronic arthritic pain with ibuprofen.

Choice B reason: Ibuprofen, an NSAID, risks gastrointestinal bleeding by inhibiting prostaglandins, weakening stomach lining protection, and impairing platelet aggregation. Symptoms like black stools or hematemesis indicate serious complications. Reporting these ensures early intervention, preventing severe outcomes like perforation or anemia, making this a critical instruction for safe use.

Choice C reason: High-intensity sunblock is relevant for photosensitizing drugs (e.g., doxycycline), not ibuprofen, which does not significantly increase photosensitivity. NSAIDs primarily affect cyclooxygenase pathways, not skin UV sensitivity. Reporting gastrointestinal bleeding is more critical, as it addresses a common, severe side effect requiring urgent attention.

Choice D reason: Ibuprofen can elevate blood pressure via sodium retention and vasoconstriction, but this is less common at standard doses. Gastrointestinal bleeding is a more frequent, severe risk, as NSAIDs disrupt gastric mucosa. Reporting bleeding symptoms takes precedence to prevent life-threatening complications, making blood pressure monitoring secondary.

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After administering lisinopril, an angiotensin-converting enzyme (ACE) inhibitor, it is most important for the nurse to monitor which assessment finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The parents of a male infant newborn have signed an informed consent for circumcision. Which priority intervention should the nurse implement upon completion of the circumcision procedure?

Correct Answer is D

Explanation

Which instruction should the nurse include in the discharge teaching plan of a client who is prescribed ibuprofen for arthritic pain?

Correct Answer is B

Explanation

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