A client with nasal congestion receives a prescription for phenylephrine 10 mg PO every 4 hours. Which client condition should the nurse report to the healthcare provider before administering the medication?
Bronchitis.
Diarrhea.
Hypertension.
Edema.
The Correct Answer is C
Choice A Reason:
Bronchitis is a condition that affects the respiratory system, and while it is important to monitor, it is not a primary concern when administering phenylephrine. Phenylephrine is a decongestant that works by narrowing the blood vessels in the nasal passages, which can help relieve congestion but does not directly impact bronchitis.
Choice B Reason:
Diarrhea is a gastrointestinal condition that, while uncomfortable, does not significantly interact with phenylephrine. It is important to manage and monitor, but it does not pose a direct risk when taking phenylephrine.
Choice C Reason:
Hypertension is a significant concern when administering phenylephrine. Phenylephrine can increase blood pressure by causing vasoconstriction. For clients with hypertension, this can exacerbate their condition and lead to serious cardiovascular complications. Therefore, it is crucial to report this condition to the healthcare provider before administering the medication.

Choice D Reason:
Edema, or swelling, can be a symptom of various underlying conditions, including heart failure or kidney issues. While it is important to monitor, it is not as directly impacted by phenylephrine as hypertension. However, any underlying condition causing edema should be considered when administering medications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Sodium polystyrene sulfonate is used to treat hyperkalemia (high potassium levels) by exchanging sodium ions for potassium ions in the intestines, which are then excreted in the stool. A serum potassium level of 3.8 mEq/L is within the normal range (3.5 to 5 mEq/L), indicating that the medication has effectively reduced the potassium level to a safe range. Monitoring potassium levels is crucial in clients with AKI to prevent complications such as cardiac arrhythmias.
Choice B Reason:
A hemoglobin level of 13.3 g/dL is slightly below the normal range for adults (14 to 18 g/dL for males and 12 to 16 g/dL for females). While it is important to monitor hemoglobin levels, this value does not directly indicate the effectiveness of sodium polystyrene sulfonate, which is specifically used to manage potassium levels.
Choice C Reason:
A serum ammonia level of 30 µg/dL is within the normal range (10 to 80 µg/dL). However, this value does not reflect the effectiveness of sodium polystyrene sulfonate, as the medication is not used to manage ammonia levels. Ammonia levels are more relevant in conditions affecting liver function, such as hepatic encephalopathy.
Choice D Reason:
A serum glucose level of 100 mg/dL is within the normal range (74 to 106 mg/dL). While it is important to monitor glucose levels, this value does not indicate the effectiveness of sodium polystyrene sulfonate. The medication’s primary function is to reduce potassium levels, not to manage glucose levels.
Correct Answer is A
Explanation
Choice A reason:
Low-density lipoprotein (LDL) is often referred to as “bad” cholesterol because high levels can lead to plaque buildup in arteries and result in heart disease and stroke. Atorvastatin is a statin medication that works by reducing the production of cholesterol in the liver, specifically targeting LDL cholesterol. Lowering LDL levels is a primary goal in managing and reducing the risk of coronary artery disease.

Choice B reason:
High-density lipoprotein (HDL) is known as “good” cholesterol because it helps remove other forms of cholesterol from the bloodstream. While atorvastatin can also help increase HDL levels, the primary indicator of its effectiveness in reducing the risk of coronary artery disease is the reduction in LDL levels.
Choice C reason:
Prothrombin time (PT) is a measure of how long it takes blood to clot. It is not directly related to the effectiveness of atorvastatin in managing cholesterol levels or reducing the risk of coronary artery disease. PT is more relevant in the context of anticoagulant therapy.
Choice D reason:
Creatine phosphokinase (CK) is an enzyme found in the heart, brain, and skeletal muscles. Elevated CK levels can indicate muscle damage, which can be a side effect of statin therapy. However, CK levels are not used to measure the effectiveness of atorvastatin in lowering cholesterol or reducing the risk of coronary artery disease.
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