A client is receiving enalapril for treatment of heart failure. Which of the following assessment findings should the nurse be concerned about following the initial administration of this drug?
1. Ototoxicity
2. Serious rash
3. Low blood pressure
4. Irregular pulse
3. Low blood pressure
Rationale:
Severe hypotension, known as first-dose phenomenon, can occur after the initial administration of enalapril. Ototoxicity is an adverse effect of loop diuretics. Stevens-Johnson syndrome, a serious rash, and an irregular pulse are adverse effects of beta-blockers.
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A nurse is caring for a client with glaucoma who is prescribed a topical beta-adrenergic blocking agent. When teaching this client about the medication, which will the nurse include?
A) Relaxes the ciliary muscle, improving the outflow of aqueous humor and reducing intraocular pressure. B) May cause blurred vision and stinging. C) When used long term, causes permanent darkening of the iris of the eye and eyebrows. D) Reduces intraocular pressure by decreasing the production of aqueous humor in the ciliary body.
A licensed practical/vocational nurse (LPN/LVN) is caring for a patient with stage 2 chronic kidney disease. Which observation by the RN requires an intervention?
a. The LPN/LVN administers the erythropoietin subcutaneously. b. The LPN/LVN assists the patient to ambulate out in the hallway. c. The LPN/LVN administers the iron supplement and phosphate binder with lunch. d. The LPN/LVN carries a tray containing low-protein foods into the patient's room.
Which cerebrospinal fluid analysis result will be most important for the nurse to communicate to the health care provider?
a. Specific gravity 1.007 b. Protein 65 mg/dL (0.65 g/L) c. Glucose 45 mg/dL (1.7 mmol/L) d. White blood cell (WBC) count 4 cells/?L
The older patient presents to the emergency department after stepping in front of a car at a crosswalk. After the patient has been triaged, the nurse interviews the patient. Which of the following comments would require follow-up by the nurse?
a. "I try to exercise, so I walk that block almost every day." b. "I waited and stepped out when the traffic sign said go." c. "The car was going too fast, the speed limit is 20." d. "I was so surprised; I didn't see or hear the car coming."