a client with a history of hypertension is prescribed lisinopril prinivil which side effect should the nurse monitor for
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Nursing Elites

ATI LPN

ATI PN Adult Medical Surgical 2019

1. A client with a history of hypertension is prescribed lisinopril (Prinivil). Which side effect should the nurse monitor for?

Correct answer: A

Rationale: The correct answer is A: Dry cough. Lisinopril is an ACE inhibitor, and a common side effect of ACE inhibitors is a dry cough. This occurs due to the accumulation of bradykinin in the lungs, leading to irritation and subsequent cough. It is important for the nurse to monitor the client for this side effect as it can affect adherence to the medication regimen. Weight gain, tachycardia, and hyperglycemia are not typically associated with lisinopril. Therefore, choices B, C, and D are incorrect.

2. During an admission physical assessment, the nurse is examining a newborn who is small for gestational age (SGA). Which finding should the nurse report immediately to the pediatric healthcare provider?

Correct answer: C

Rationale: A widened, tense, bulging fontanel is a critical finding in a newborn as it can indicate increased intracranial pressure. This condition requires immediate attention and intervention to prevent further complications. Monitoring fontanel status is crucial in assessing the newborn's neurological well-being and ensuring early detection of potential issues.

3. A client with osteoporosis is being discharged home. Which instruction should the nurse include in the discharge teaching?

Correct answer: B

Rationale: Taking calcium supplements with meals is a crucial instruction for a client with osteoporosis. Calcium absorption is enhanced when taken with food, and proper calcium intake is essential for managing osteoporosis effectively by promoting bone health and density. Avoiding weight-bearing exercises (Choice A) is incorrect because these exercises help improve bone strength. Limiting vitamin D intake (Choice C) is also incorrect as vitamin D is necessary for calcium absorption. Increasing caffeine intake (Choice D) is not recommended as caffeine can interfere with calcium absorption.

4. An 85-year-old male resident of an extended care facility reaches for the hand of an unlicensed assistive personnel (UAP) and tries to kiss her hand several times during his morning care. The UAP reports the incident to the charge nurse. What is the best assessment of the situation?

Correct answer: C

Rationale: In this scenario, the resident's actions of reaching for the UAP's hand and trying to kiss it could indicate a need for touch rather than intentional sexual harassment. The best assessment is to consider the possibility that the client may be experiencing touch deprivation and is seeking appropriate ways to express his need for physical contact. Providing guidance on acceptable ways to seek physical affection can help address the underlying issue and improve the resident's interactions with the staff. Choice A is incorrect because assuming sexual harassment without understanding the context and potential reasons behind the behavior can lead to misinterpretation. Choice B is inappropriate as reassignment based on gender is not a solution and does not address the root cause of the behavior. Choice D is not the best approach as it focuses solely on setting boundaries without considering the resident's underlying need for touch.

5. A client with a history of asthma is prescribed salmeterol (Serevent). Which instruction should the nurse provide?

Correct answer: C

Rationale: The correct instruction for a client prescribed salmeterol (Serevent) is to use it twice daily for long-term control. Salmeterol is a long-acting bronchodilator that is not intended for acute asthma attacks or as-needed use for wheezing. Choice A is incorrect because salmeterol is not used for acute asthma attacks. Choice B is incorrect as salmeterol is not meant to replace the albuterol inhaler but rather used for long-term control. Choice D is incorrect because salmeterol should not be used as needed; it is a maintenance medication for asthma.

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