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 A

Explanation

Choice A reason: Excessive levothyroxine causes hyperthyroidism, increasing T3/T4, stimulating beta-adrenergic receptors, leading to palpitations (tachycardia) and shortness of breath from heightened cardiac workload and oxygen demand. These indicate overdose, risking atrial fibrillation, requiring immediate dose adjustment to prevent cardiovascular complications in this thyroid-treated client.

Choice B reason: Lethargy and lack of appetite suggest hypothyroidism, indicating low thyroid hormone levels from insufficient levothyroxine. These are opposite to overdose symptoms like palpitations, driven by excessive metabolism. High doses cause hyperthyroid effects, making this incorrect for identifying excessive dosing in goiter treatment.

Choice C reason: Muscle cramps and dry, flushed skin are not typical of levothyroxine overdose. Hyperthyroidism causes warm, moist skin from increased metabolism, not dryness. Cramps relate to electrolytes. Palpitations and shortness of breath are hallmark overdose signs, reflecting thyroid-driven cardiovascular overstimulation, making this less accurate.

Choice D reason: Bradycardia and constipation indicate hypothyroidism from low thyroid hormones, reducing heart rate and metabolism. This suggests inadequate levothyroxine, not overdose. Excessive doses cause hyperthyroidism, with palpitations and dyspnea from metabolic hyperactivity, making these symptoms incorrect for high-dose levothyroxine effects.

A. Acetaminophen 650 mg PO PRN. B. Olanzapine 30 mg PO at bedtime. C. Thiamine, USP 100 mg PO daily. D. Ondansetron 8 mg IV PRN.

Correct Answer is A

Explanation

Choice A reason: Acetaminophen is hepatotoxic, metabolized by the liver via cytochrome P450 to NAPQI, which depletes glutathione, causing necrosis in hepatitis. A compromised liver from alcohol or viral hepatitis increases toxicity risk, even at standard doses. Contacting the provider ensures safer analgesics, preventing further liver damage in this high-risk client.

Choice B reason: Olanzapine, an antipsychotic, manages schizophrenia by blocking dopamine D2 receptors. It is metabolized by the liver but has low hepatotoxicity risk compared to acetaminophen in hepatitis. No immediate contraindication exists, as it controls psychosis without significantly worsening liver function, making it safe to administer without delay.

Choice C reason: Thiamine (vitamin B1) is essential in hepatitis, particularly with alcohol abuse, preventing Wernicke’s encephalopathy from deficient glucose metabolism. It is liver-safe and beneficial, supporting neurological function without toxicity. Administering thiamine is appropriate, making it unnecessary to contact the provider before implementation.

Choice D reason: Ondansetron, an antiemetic, controls nausea in hepatitis via serotonin 5-HT3 receptor blockade. It is metabolized by the liver but has minimal hepatotoxicity, safe in liver disease. No contraindication exists, as it alleviates symptoms without worsening hepatitis, unlike acetaminophen, which poses significant liver risk.

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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

A client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client?

Correct Answer is A

Explanation

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?

Correct Answer is A

Explanation

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

An older adult male client with schizophrenia is found smearing feces on the bathroom walls of the chronic mental health unit where he resides. Which action should the nurse implement?

A client with gastroesophageal reflux disorder (GERD), who has been self-medicating with famotidine for the past week, is admitted to the acute care center because the symptoms have worsened. The nurse should anticipate which treatment?

After a week of bedrest, a client is being assisted to a chair for the first time. The nurse raises the head of the bed and moves the client to a sitting position. Which action should the nurse implement next?

An older male client reports nocturia with difficulty starting his urine stream. Which additional assessment should the nurse perform to obtain further data related to this information?

The nurse is providing teaching to a client with type 2 diabetes mellitus about important points for disease and symptom management. Which statement by the client indicates understanding?

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

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?