Author Question: A nurse just administered the first dose of an ACE inhibitor to her patient 1 hour ago. The patient, ... (Read 66 times)

karateprodigy · **on:** Jul 23, 2018

A nurse just administered the first dose of an ACE inhibitor to her patient 1 hour ago. The patient, who is resting supine, urgently asks to go to the bathroom. The nurse's best action would be which of the following interventions?

a. Provide a bedside commode.
b. Provide a bed pan.
c. Assist the patient to the bathroom immediately.
d. Allow the patient to dangle the legs on the side of the bed for a few minutes.

Question 2

A nurse is performing a physical assessment on a patient with heart failure. If Starling's law were to break down, what is the most significant clinical manifestation the patient could display?

a. Increased heart rate
b. Decreased blood volume
c. Increased blood pressure
d. Shortness of breath

coyin · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

ANS: B
Severe hypotension can result with the first dose of an ACE inhibitor. The patient should be discouraged from getting up, and a bed pan should be provided.
Providing a bedside commode or assisting the patient to the bathroom, even after dangling the legs on the side of the bed, is contraindicated at this time.

Answer to Question 2

ANS: D
In a failing heart, Starling's law breaks down. The force of contraction no longer increases in proportion to increased ventricular filling. Blood backs up behind the failing ventricle, which causes blood to back up in the pulmonary circulation. This leads to respiratory symptoms, including dyspnea, or shortness of breath.
An increased heart rate would be expected because of the increase in volume; however, this would not be the most significant finding related to heart failure.
The patient would not have a decrease in blood volume.
An increase in blood pressure probably would be expected, but this would not be the most significant finding related to heart failure.