Author Question: A client is receiving enalapril for treatment of heart failure. Which of the following assessment ... (Read 71 times)

OSWALD · **on:** Jul 22, 2018

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

Question 2

The nurse is planning a teaching program in anticipation of the discharge of a client with a urinary diversion. Which of the following points will the nurse incorporate into the plan?

1. Change the appliance every day.
2. Increase fluid intake.
3. Notify the physician if the stoma is deep pink and shiny.
4. Strands of blood may appear in the urine.

momolu · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

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.

Answer to Question 2

2. Increase fluid intake.

Rationale:
Increasing the fluid intake helps to flush out sediment and mucus and prevents clogging of the stoma. The appliance should be changed every 5 to 7 days. Every day changing is unnecessary. A deep pink, shiny stoma is normal and does not require the notification of the physician. Strands of mucus, not blood, may appear in urine because of the mucus-producing cells of the ileum.