The nurse is caring for a patient who was recently placed on lisinopril to control hypertension. What teaching will the nurse provide?

Let your provider know if a new cough occurs

Take the medication on a full stomach

This medication will not cause edema

Eat a high potassium diet

Answer and Explanation

The Correct Answer is A

A. Let your provider know if a new cough occurs:
This teaching is essential because lisinopril, an angiotensin-converting enzyme (ACE) inhibitor, is associated with a potential side effect of a persistent, dry cough. Notifying the healthcare provider if a new cough develops allows for appropriate management, such as discontinuation or adjustment of the medication to alleviate the symptom.

B. Take the medication on a full stomach:
Taking lisinopril with or without food is acceptable, as it does not significantly affect its absorption. However, taking it on an empty stomach is often recommended to optimize absorption. Advising the patient to take the medication on a full stomach is incorrect and may lead to misunderstandings.

C. This medication will not cause edema:
Lisinopril, as an ACE inhibitor, may actually cause or exacerbate edema as a side effect. It can lead to vasodilation and fluid retention, particularly in susceptible individuals. Providing incorrect information about the medication's potential side effects can compromise patient understanding and safety.

D. Eat a high potassium diet:
Lisinopril can increase serum potassium levels, so instructing the patient to consume a high-potassium diet may exacerbate this effect and lead to hyperkalemia. While dietary potassium intake should be monitored, advising a high-potassium diet without proper guidance can pose risks to the patient's health.

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Correct Answer is C

Explanation

A. Monitors the patient's temperature, heart rate, respiratory rate, and blood pressure:
Monitoring vital signs is crucial for assessing the patient's overall condition, including respiratory status. However, while changes in vital signs may indicate respiratory distress, they do not directly address the need to ensure clear breath sounds. This intervention alone does not actively promote airway clearance or improve breath sounds.

B. Educates the patient to avoid handling pet excreta or cleaning litter boxes, birdcages, or aquariums:
This intervention focuses on reducing the risk of exposure to potential pathogens that could worsen the patient's respiratory condition. While important for infection control, it does not directly address the need to ensure clear breath sounds. Environmental precautions, although necessary, do not actively promote airway clearance or improve breath sounds.

C. Encourages the patient to perform cough, deep breathing, and postural drainage every 2 to 4 hours:
This intervention directly targets promoting airway clearance and improving breath sounds in a patient with pneumonia. Coughing helps mobilize secretions, deep breathing promotes lung expansion and ventilation, and postural drainage assists in the drainage of secretions from different lung segments. Regular performance of these interventions prevents secretion accumulation, thereby improving breath sounds and respiratory function.

D. Provides nutritional support if the patient is unable to take sufficient amounts by mouth:
While nutritional support is important for overall patient care, especially during illness or compromised nutritional intake, it does not directly address the need to ensure clear breath sounds in a patient with pneumonia. Although adequate nutrition supports immune function and overall recovery, it does not directly impact respiratory clearance or breath sounds.

A. Loss of hair over toes. B. Tenderness in the thigh. C. Rest pain. D. Auscultation of bruit over pedal pulse.

Correct Answer is B

Explanation

A. Loss of hair over toes:
Loss of hair over the toes is not typically associated with deep vein thrombosis (DVT). Instead, it may be indicative of peripheral arterial disease (PAD) or poor peripheral circulation. In DVT, symptoms are more related to venous congestion and inflammation rather than hair loss.

B. Tenderness in the thigh:
Tenderness in the thigh is a common clinical manifestation of deep vein thrombosis (DVT). It occurs due to the presence of a thrombus within the deep veins of the thigh, causing local inflammation and irritation of the vessel wall. This tenderness may be elicited by palpation along the course of the affected vein.

C. Rest pain:
Rest pain is not typically associated with deep vein thrombosis (DVT). Rest pain is more commonly seen in conditions such as peripheral arterial disease (PAD), where inadequate blood supply to the extremities leads to ischemic pain at rest, especially during periods of reduced blood flow.

D. Auscultation of bruit over pedal pulse:
Auscultation of a bruit over the pedal pulse is not typically associated with deep vein thrombosis (DVT). A bruit is an abnormal sound caused by turbulent blood flow through a narrowed or obstructed vessel, commonly heard in arterial conditions such as atherosclerosis. In DVT, venous obstruction does not typically produce bruits.

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The nurse is caring for a patient who was recently placed on lisinopril to control hypertension. What teaching will the nurse provide?

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