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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

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

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A reason: Denying muscle spasms is normal and not a complication. Muscle twitching indicates hypocalcemia, a thyroidectomy risk due to parathyroid damage. Absence of spasms is reassuring, per postoperative complication monitoring and endocrine surgical care standards in nursing.

Choice B reason: Back and joint pain are nonspecific and not typical thyroidectomy complications. Muscle twitching suggests hypocalcemia, a critical issue post-thyroidectomy. Pain requires assessment but is less urgent, per postoperative monitoring and complication management protocols in surgical nursing.

Choice C reason: Muscle twitching in hands and feet indicates hypocalcemia, a serious complication from parathyroid gland damage during thyroidectomy. This requires immediate calcium replacement to prevent tetany, per postoperative complication monitoring and endocrine surgical care protocols in nursing practice.

Choice D reason: Diaphoresis without headache is nonspecific and not a primary thyroidectomy complication. Muscle twitching signals hypocalcemia, needing urgent intervention. Diaphoresis requires monitoring but is less critical, per postoperative assessment and complication management standards in surgical nursing.

A. Elevate the client’s right hand on one or two pillows. B. Measure the client’s blood pressure and apical heart rate. C. Complete a neurovascular assessment of the right hand. D. Notify the healthcare provider quickly.

Correct Answer is C

Explanation

Choice A reason: Elevating the hand reduces edema, potentially improving circulation, but is premature without assessing the absent radial pulse’s cause. Post-fracture, compartment syndrome or arterial injury risks ischemia. Neurovascular assessment identifies severity, guiding targeted interventions to restore perfusion, making elevation secondary to assessment.

Choice B reason: Measuring blood pressure and heart rate provides systemic data but not localized insight into the absent radial pulse, likely from arterial compression post-surgery. Neurovascular assessment evaluates limb perfusion, detecting compartment syndrome or occlusion, critical for urgent intervention to prevent tissue necrosis.

Choice C reason: Completing a neurovascular assessment evaluates pulse, color, warmth, sensation, and movement. Absent radial pulse post-fracture suggests compartment syndrome or arterial injury, risking ischemia. This confirms vascular compromise, guiding interventions like fasciotomy, addressing the pathophysiological threat to limb viability, ensuring timely treatment.

Choice D reason: Notifying the provider follows assessment. Absent radial pulse suggests compartment syndrome, where swelling impairs arterial flow. Neurovascular assessment quantifies severity (e.g., pallor, paresthesia), ensuring accurate reporting for urgent intervention, preventing delays in treating vascular compromise critical to limb preservation.

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

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

Following a total thyroidectomy, the nurse plans to observe a client for complications. Which finding indicates that the client has developed a complication?

Correct Answer is C

Explanation

Four hours following surgical repair of a compound fracture of the right ulna, the nurse is unable to palpate the client’s right radial pulse. Which action should the nurse take first?

Correct Answer is C

Explanation

A client is admitted to the hospital with symptoms consistent with a right hemisphere stroke. Which neurovascular assessment requires immediate intervention by the nurse?

The nurse is initiating a 24-hour urine collection for a client with an indwelling urinary catheter. After emptying all the urine from the collection bag, which action is most important for the nurse to implement?

A client with a history of schizophrenia, and drug and alcohol abuse is admitted to the hospital for hepatitis. The nurse should contact the healthcare provider before implementing which prescription?

The nurse is assessing a client with a history of heart failure who reports new-onset dyspnea and fatigue. Which finding requires the most immediate intervention?

After a client voids, 150 mL of residual urine is measured. Which nursing problem should be included in this client’s plan of care?

Which serum laboratory test is most important for the nurse to monitor when administering enoxaparin to a client?

A client with a history of atrial fibrillation is prescribed warfarin. The nurse notes the client’s INR is 4.8. Which action should the nurse take? Reference Range: INR [2.0 to 3.0 for atrial fibrillation].