Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assessing a client who is taking telmisartan. The nurse should identify that which of the following findings indicates that the medication has been effective?
A. Respiratory rate of 16/min
B. Decrease in blood pressure
Telmisartan is an angiotensin II receptor blocker (ARB) used to treat hypertension by lowering blood pressure. Therefore, a decrease in blood pressure would suggest that the medication is working as intended. Telmisartan has no effect on respiratory rate, urine output or blood glucose.
C. Increase in urinary output
D. Blood glucose of 110 mg/dL
This question is an excerpt from Nurse Dive's nursing test bank - Ati Rn Adult Medical Surgical 2023 Proctored Exam. Take the full exam now
Full Explanation
Telmisartan is an angiotensin II receptor blocker (ARB) used to treat hypertension by lowering blood pressure. Therefore, a decrease in blood pressure would suggest that the medication is working as intended.
Telmisartan has no effect on respiratory rate, urine output or blood glucose.
Similar Questions
A nurse is caring for a client who is receiving mechanical ventilation when the low-pressure alarm sounds on the ventilator. Which of the following actions should the nurse take?
A. Suction the client's airway.
Suctioning the client's airway is not the appropriate action in response to a low-pressure alarm on the ventilator.
B. Empty water from the client's ventilator tubing.
Emptying water from the client's ventilator tubing could be a valid action to take if there is excess condensation or water buildup in the ventilator tubing causing the low-pressure alarm. However, it's not the first action to consider, as other causes should be ruled out first.
C. Increase the client's ventilator flow rate.
Increasing the ventilator flow rate may help maintain adequate pressure in the ventilator circuit and address the low-pressure alarm if the cause is related to insufficient airflow. However, adjusting the flow rate should be done cautiously and based on the client's respiratory status and ventilator settings.
D. Evaluate the client for a cuff leak.
Evaluate the client for a cuff leak is the most appropriate action in response to a low-pressure alarm on the ventilator. A cuff leak can cause a drop in ventilator pressure, triggering the alarm. Assessing the client's cuff for leaks and addressing any identified issues can help resolve the alarm and ensure adequate ventilation.
Full Explanation
D. Evaluate the client for a cuff leak is the most appropriate action in response to a low-pressure alarm on the ventilator. A cuff leak can cause a drop in ventilator pressure, triggering the alarm. Assessing the client's cuff for leaks and addressing any identified issues can help resolve the alarm and ensure adequate ventilation.
A. Suctioning the client's airway is not the appropriate action in response to a low-pressure alarm on the ventilator.
B. Emptying water from the client's ventilator tubing could be a valid action to take if there is excess condensation or water buildup in the ventilator tubing causing the low-pressure alarm. However, it's not the first action to consider, as other causes should be ruled out first.
C. Increasing the ventilator flow rate may help maintain adequate pressure in the ventilator circuit and address the low-pressure alarm if the cause is related to insufficient airflow. However, adjusting the flow rate should be done cautiously and based on the client's respiratory status and ventilator settings.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following nursing actions are appropriate? (Select all that apply.)
A. Increase the rate of infusion if administration is delayed.
TPN solutions must be administered according to the prescribed rate and schedule. Increasing the infusion rate without medical orders could lead to complications such as hyperglycemia or fluid overload.
B. Monitor serum blood glucose during infusion.
Monitoring serum blood glucose during infusion is important because TPN can contain glucose, which may affect the client's blood glucose levels. Regular monitoring helps ensure glycemic control and prevents complications such as hyperglycemia.
C. Verify the solution with another RN prior to infusion.
Double-checking the TPN solution with another RN is a crucial safety measure to prevent medication errors and ensure that the correct solution is administered to the client.
D. Infuse 0.9% sodium chloride if the solution is not available.
TPN solutions are specifically formulated to meet the client's nutritional needs and cannot be substituted with other intravenous solutions like 0.9% sodium chloride.
E. Obtain the client's weight daily.
Monitoring the client's weight daily is important for assessing fluid balance and adjusting the TPN infusion rate accordingly. Changes in weight can indicate fluid retention or loss, which may require adjustments to the TPN prescription.
Full Explanation
B. Monitoring serum blood glucose during infusion is important because TPN can contain glucose, which may affect the client's blood glucose levels. Regular monitoring helps ensure glycemic control and prevents complications such as hyperglycemia.
C. Double-checking the TPN solution with another RN is a crucial safety measure to prevent medication errors and ensure that the correct solution is administered to the client.
E. Monitoring the client's weight daily is important for assessing fluid balance and adjusting the TPN infusion rate accordingly. Changes in weight can indicate fluid retention or loss, which may require adjustments to the TPN prescription.
A. TPN solutions must be administered according to the prescribed rate and schedule. Increasing the infusion rate without medical orders could lead to complications such as hyperglycemia or fluid overload.
D. TPN solutions are specifically formulated to meet the client's nutritional needs and cannot be substituted with other intravenous solutions like 0.9% sodium chloride.
A nurse is teaching a client who has a new prescription for warfarin about foods that affect the INR. The nurse should include in the teaching that which of the following foods interacts with this medication?
A. Orange juice
B. Beef stew
C. Kale
Kale is high in vitamin K, which can antagonize the effects of warfarin. Warfarin works by inhibiting vitamin K-dependent clotting factors, so consuming large amounts of vitamin K-rich foods like kale can reduce the anticoagulant effect of warfarin, leading to a decrease in the INR. Orange juice, beef stew and yogurt have no interactions with warfarin.
D. Yogurt
Full Explanation
Kale is high in vitamin K, which can antagonize the effects of warfarin. Warfarin works by inhibiting vitamin K-dependent clotting factors, so consuming large amounts of vitamin K-rich foods like kale can reduce the anticoagulant effect of warfarin, leading to a decrease in the INR.
Orange juice, beef stew and yogurt have no interactions with warfarin.