A nurse is assisting in the care of a client who is taking chlorpromazine. Which of the following findings indicates a therapeutic effect medication?

A) *Restrict your daily fluid intake: Restricting fluid intake is not recommended for a client experiencing lightheadedness upon standing, especially when taking an ACE inhibitor. In fact, maintaining adequate hydration is important to help prevent hypotension, which could be exacerbated by fluid restriction. The lightheadedness may be due to orthostatic hypotension, which is a common side effect of ACE inhibitors.

B) *Take a daily potassium supplement: ACE inhibitors can increase potassium levels in the blood, potentially leading to hyperkalemia. For most clients, taking a potassium supplement is not necessary unless specified by the healthcare provider. In fact, many clients taking ACE inhibitors need to avoid excessive potassium intake, unless directed otherwise, to prevent dangerous potassium levels.

C) *Discontinue this medication if this occurs again: The nurse should not advise the client to discontinue the medication without consulting the healthcare provider. Lightheadedness upon standing is a common side effect of ACE inhibitors due to their blood pressure-lowering effects, and the healthcare provider should be notified if this becomes problematic. The decision to change or discontinue the medication should be made by the provider.

D) "Sit back down for a few minutes when this occurs": This is the most appropriate advice. Lightheadedness upon standing can be a sign of orthostatic hypotension, which is a known side effect of ACE inhibitors. The client should be instructed to sit down and rest when they experience these symptoms. If necessary, they should stand up slowly to allow their body to adjust to changes in position, which can help alleviate the lightheadedness.

A) Instruct another nurse to record the prescription in the medical record:
The nurse receiving a telephone prescription is responsible for ensuring the prescription is recorded correctly in the medical record. It is not appropriate to delegate this responsibility to another nurse. The nurse should personally document the prescription to ensure accuracy and clarity.

B) Withhold the medication until the provider signs the prescription:
The nurse should not withhold the medication solely based on the provider's signature. Telephone prescriptions are valid once they are received and documented accurately by the nurse. The prescription must be signed by the provider as soon as possible, but withholding medication is not warranted unless there are other concerns with the prescription.

C) Ask the provider to spell out the name of the medication:
When receiving a telephone prescription, the nurse should ask the provider to spell out the name of the medication to avoid errors. Medication names, especially those that sound similar, need to be communicated clearly to ensure correct medication administration. This action helps prevent misinterpretation or confusion, ensuring patient safety.

D) Record the date and time of the telephone prescription:
Recording the date and time of the telephone prescription is essential for accurate documentation and legal purposes. This step ensures that there is a clear record of when the prescription was given and that the provider’s order is traceable in the client’s medical record. It also assists in meeting legal and institutional documentation requirements.

E) Request that the provider confirm the read-back of the prescription:
The nurse should read back the prescription to the provider to confirm accuracy. This action is part of the "read-back" process, a safety measure used to verify that the prescription has been communicated correctly and understood by both the nurse and the provider. This step helps reduce the risk of medication errors.