A nurse is caring for client who is taking lisinopril (ACE inhibitor). Which of the following outcomes indicates a therapeutic effect of the medication?

A) Wait 10 sec after placing the probe before obtaining the oxygen saturation reading:
While a brief wait may be necessary for the pulse oximeter to adjust and display a stable reading, there is no need to wait a full 10 seconds after placing the probe before obtaining the reading. Typically, the device should provide an accurate reading within a few seconds after placement.

B) Place the sensor probe on the same extremity as an electronic blood pressure cuff:
The blood pressure cuff can interfere with the oxygen saturation measurement by constricting the blood flow to the extremity. Placing the pulse oximeter sensor on the same arm or hand as the blood pressure cuff could lead to inaccurate readings due to decreased circulation or occlusion of blood flow. It's best to place the pulse oximeter sensor on a different extremity from the cuff.

C) Relocate the sensor every 8 hrs:
This is not necessary unless there are signs of skin breakdown or compromised circulation under the probe. Typically, a pulse oximeter sensor can be left in place on a single site for several hours if it is well-tolerated by the patient. Frequent moving of the sensor could cause unnecessary discomfort or risk of skin irritation, and it's not a routine requirement.

D) Choose a finger with a capillary refill less than 2 sec:
The accuracy of pulse oximetry readings can be influenced by peripheral circulation. A finger with a capillary refill of less than 2 seconds indicates good peripheral perfusion, which is ideal for obtaining an accurate oxygen saturation measurement. Poor circulation, such as that seen with cold extremities or compromised blood flow, can lead to inaccurate readings, so ensuring the finger has adequate circulation is important.

A) The client reports dizziness when ambulating to the bathroom:
Dizziness upon ambulation is a key indicator that the client may be experiencing orthostatic hypotension, a potential side effect of antihypertensive medications. If the client is already experiencing dizziness, this could be exacerbated by administering the medication, which may cause a further drop in blood pressure. It is crucial for the nurse to further assess the client’s blood pressure (particularly orthostatic blood pressure readings) and overall clinical status before administering the medication to prevent potential falls, injury, or worsening hypotension.

B) The client reports having trouble sleeping the previous night:
While difficulty sleeping could be a concern, it is not directly related to the administration of an antihypertensive medication unless the client reports other symptoms, such as palpitations, chest pain, or anxiety, which may indicate an underlying issue. It is not a priority to delay or further assess medication administration based solely on sleep disturbances unless other significant factors are present.

C) The client ate 60% of their breakfast:
Eating 60% of the meal is not typically a reason to withhold or delay antihypertensive medication unless the client is showing signs of severe nausea, vomiting, or gastrointestinal distress. Many antihypertensive medications can be taken with food to reduce gastric irritation, and this percentage of food intake does not pose an immediate concern.

D) The client has a urine output of 400 mL for the past 8 hours:
Urine output of 400 mL over 8 hours is within the normal range (approximately 50–60 mL/hr), suggesting adequate renal function and fluid balance. While a decrease in urine output can be concerning, there is no immediate indication that this level of output would interfere with the administration of an antihypertensive medication.