Process
10th Edition
• Author(s)Linda Lane Lilley;
Shelly Rainforth Collins; Julie
S. Snyder
,TEST BANK
Question 1
Item Type
Multiple Choice (MCQ)
Clinical Scenario
A nurse is preparing to administer the first dose of lisinopril to a
hospitalized adult with newly diagnosed hypertension. The
patient's blood pressure is 98/60 mm Hg, potassium level is 5.6
mEq/L, and serum creatinine has increased since admission.
The patient reports feeling dizzy when standing.
Question Stem
Which nursing action is the priority before administering the
medication?
Options
A. Administer the medication with breakfast.
B. Hold the medication and notify the healthcare provider.
C. Encourage increased dietary potassium intake.
D. Reassess blood pressure in 8 hours.
,Correct Answer
B. Hold the medication and notify the healthcare provider.
Comprehensive Rationale
The nursing process begins with assessment. Before medication
administration, the nurse must evaluate whether current
assessment findings indicate that therapy may be unsafe.
ACE inhibitors can:
• Lower blood pressure further
• Increase serum potassium
• Reduce glomerular filtration in susceptible patients
This patient demonstrates multiple findings requiring
reassessment before administration:
• Symptomatic hypotension
• Hyperkalemia
• Worsening renal function
Administering the medication without evaluating these findings
increases the risk for severe hypotension, dysrhythmias from
hyperkalemia, and further kidney injury.
, Distractor Analysis
A. Administer with breakfast
• Incorrect because meal timing does not address safety
concerns.
• Common misconception: Food administration is more
important than patient assessment.
• Medication safety risk: Administering despite
contraindicating assessment findings.
• Appropriate action: Complete assessment before
administration.
C. Encourage dietary potassium
• Incorrect.
• ACE inhibitors commonly increase potassium.
• Additional potassium could worsen hyperkalemia.
• Nurse should review potassium intake restrictions.
D. Reassess in 8 hours
• Incorrect because immediate intervention is required.