A nurse reviews findings for clients receiving antihypertensive medications. For each finding, select the best response classification.
Matrix
Choose your responses, then check the answer.
Explanation
A stable dry cough with lisinopril and isolated bilateral ankle edema with amlodipine require assessment and follow-up but are not automatically emergencies. Tongue or lip swelling with stridor suggests ACE-inhibitor angioedema and requires emergency airway action. Symptomatic bradycardia with metoprolol, potassium 2.8 mEq/L with furosemide, and sodium 124 mEq/L with confusion during thiazide therapy require prompt medication-safety assessment, appropriate dose handling under the order or protocol, and clinician notification. Do not invent universal hold thresholds when none are prescribed.
Quick answer Separate common follow-up findings from symptomatic vital-sign or electrolyte abnormalities and from airway-threatening angioedema.
Why this is correct ACE inhibitors commonly cause cough but can rarely cause dangerous angioedema. Beta blockers can cause clinically important bradycardia. Loop and thiazide diuretics can produce electrolyte depletion, while amlodipine commonly causes dose-related edema. The response depends on severity and the complete cue pattern.
Easy analogy or mental picture Use three lanes: routine follow-up, prompt safety review, and emergency airway response. Put each cue in the lane that matches its immediate risk.
Memory hook Cough: follow up. Slow pulse or low electrolytes with symptoms: assess promptly. Swollen tongue or stridor: airway emergency.
NCLEX decision rule Review symptoms, vital signs, renal function, and electrolytes before administering or holding medication. Use prescribed parameters and organizational policy; escalate severe bradycardia, marked electrolyte abnormalities, syncope, or airway swelling rather than applying an invented universal number.
Why the other choices are wrong Not every cough or ankle edema is an emergency, but both deserve assessment. Conversely, angioedema, symptomatic bradycardia, and severe electrolyte abnormalities should not be deferred to routine teaching or the next visit.
Source
1DailyMed Lisinopril Label
2DailyMed Metoprolol and Hydrochlorothiazide Label
3DailyMed Furosemide Label
4DailyMed Amlodipine Label
52026 NCLEX-RN Test Plan
The nurse is comparing common nonemergent effects with findings that require a dose-safety assessment or emergency action. No universal facility hold parameters are provided; decisions must use the client's symptoms, vital signs, laboratory results, and prescribed parameters.
ACE-inhibitor angioedema — Potentially life-threatening swelling of the lips, tongue, face, or airway associated with an angiotensin-converting enzyme inhibitor.
Symptomatic bradycardia — A slow heart rate accompanied by findings such as dizziness, hypotension, syncope, chest discomfort, or altered perfusion.
Diuretic-associated electrolyte depletion — Loss of electrolytes such as potassium or sodium during diuretic therapy that can cause weakness, confusion, cramps, or dysrhythmias.