A client with a history of heart failure and hypertension is in the clinic for a follow-up visit. The client is on lisinopril (Prinivil) and warfarin (Coumadin). The client reports new-onset cough. What action by the nurse is most appropriate?
a. Assess the client's lung sounds and oxygenation.
b. Instruct the client on another antihypertensive.
c. Obtain a set of vital signs and document them.
d. Remind the client that cough is a side effect of Prinivil.
ANS: A
This client could be having an exacerbation of heart failure or be experiencing a side effect of lisinopril (and other angiotensin-converting enzyme inhibitors). The nurse should assess the client's lung sounds and other signs of oxygenation first. The client may or may not need to switch antihypertensive medications. Vital signs and documentation are important, but the nurse should assess the respiratory system first. If the cough turns out to be a side effect, reminding the client is appropriate, but then more action needs to be taken.
You might also like to view...
You are a nurse manager on the 11 p.m. to 7 a.m. shift. You periodically make rounds, observing and checking on your staff and residents. You do this on a regular basis throughout your shift because:
1. your facility requires you to do so. 2. the policy manual states this as a regulation. 3. you are responsible for the behavior of those you manage. 4. state law requires this action.
The nurse notes that the patient has a history of "fibroids" and is aware that this term, which refers to a benign tumor of the uterus, is more appropriately termed a:
A) Bartholin's cyst B) Dermoid cyst C) Hydatidiform mole D) Leiomyoma
A patient is taking intravenous aminophylline for a severe exacerbation of chronic obstructive pulmonary disease. The nurse will assess for which therapeutic response?
a. Increased sputum production b. Increased heart rate c. Increased respiratory rate d. Increased ease of breathing
The nurse gives 800 mg of a drug that has a half-life of 8 hours. How much drug will be left in the body in 24 hours if no additional drug is given?
a. None b. 50 mg c. 100 mg d. 200 mg