# A 60-year-old client started on lisinopril 10 mg orally daily for newly diagnosed hypertension calls the clinic 2 weeks later reporting a "persistent dry, tickling cough that keeps me awake at night." The client denies fever, dyspnea, or sputum. Which response by the nurse is most appropriate?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=374901&lang=en  
> language: en  
> subject: Medical Emergencies  
> category: PA

## Question

A 60-year-old client started on lisinopril 10 mg orally daily for newly diagnosed hypertension calls the clinic 2 weeks later reporting a "persistent dry, tickling cough that keeps me awake at night." The client denies fever, dyspnea, or sputum. Which response by the nurse is most appropriate?

## Option

1. "You can stop taking lisinopril for a few days to see if the cough goes away, and then restart it if the coughing does not return."
2. "Continue the lisinopril and use an over-the-counter cough suppressant containing dextromethorphan to control the dry cough."
3. "The cough indicates that the medication is effectively lowering your blood pressure by reducing afterload and improving cardiac function."
4. "This is a known side effect of ACE inhibitors caused by bradykinin buildup; the provider may switch you to an ARB such as losartan." **✔ Correct answer**

**Correct answer: 4**

## Explanation

ACE inhibitor dry cough
ACE inhibitors (-pril) inhibit the conversion of angiotensin I to angiotensin II and concurrently slow the breakdown of bradykinin. Accumulated bradykinin causes a dry, persistent, tickling, non-productive cough in 5-20% of patients, more common in women and certain ethnic groups, and can occur weeks to months after initiation. The cough does not respond to OTC cough syrup, but resolves within 1-4 weeks of discontinuation. The standard management is provider notification and a switch to an angiotensin receptor blocker (ARB, -sartan) — losartan, valsartan, olmesartan — which provides the same RAAS blockade without bradykinin accumulation. The nurse must not advise self-discontinuation (rebound HTN risk) or downplay the symptom.

## In-depth explanation

Why option 2 is correct
ACE inhibitors (-pril drugs) block conversion of angiotensin I to angiotensin II and also decrease bradykinin breakdown. Bradykinin accumulation can cause a dry, tickling, nonproductive cough in about 5-20% of clients, often weeks to months after initiation. OTC cough syrup usually does not help; the cough typically resolves 1-4 weeks after discontinuation. Standard management is to notify the prescriber and switch to an ARB (-sartan, such as losartan, valsartan, or olmesartan), which provides RAAS blockade without bradykinin buildup.

Distractor review
Option 1: ACE inhibitor cough does not reliably resolve within 48 hours and is not treated with OTC syrup alone. Option 3: self-discontinuation can cause rebound hypertension and cardiovascular risk. Option 4: the cough is an adverse effect, not a beneficial sign.

Cross-pharmacology point
After switching to an ARB, first-dose hypotension, hyperkalemia, and rare angioedema still require monitoring, but dry cough is much less common. New cough in a long-term ACE inhibitor user should still prompt assessment for other causes such as pneumonia or postnasal drip.

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