A nurse is making a follow-up call to a client who has a new prescription for an ACE Inhibitor to treat hypertension. The client reports lightheadedness upon standing. Which of the following statements should the nurse make?
"Sit back down for a few minutes when this occurs."
"Discontinue this medication if this occurs again."
Restrict your daily fluid intake."
"Take a daily potassium supplement."
The Correct Answer is A
A. Correct. Lightheadedness upon standing, also known as orthostatic hypotension, can be a common side effect of ACE inhibitors. Advising the client to sit down when experiencing lightheadedness will help prevent falls.
B. Incorrect. Discontinuing the medication without consulting a healthcare provider is not appropriate. Lightheadedness can be managed with strategies like changing positions slowly.
C. Incorrect. Restricting fluid intake is not necessary unless advised by a healthcare provider.
Adequate hydration is important, especially with the use of certain medications.
D. Incorrect. While potassium supplements might be prescribed in some cases with ACE inhibitors, the primary concern in this situation is addressing orthostatic hypotension.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Incorrect. Plaster casts are not waterproof and can become weakened if exposed to moisture, so showering with the cast is generally not recommended.
B. Correct. Elevating the extremity can help reduce swelling and promote comfort after the cast is applied.
C. Incorrect. Using a hair dryer inside the cast can cause burns and is not recommended for relieving itching.
D. Incorrect. Keeping the cast covered is not necessary, and covering it can trap moisture, potentially causing skin problems.
Correct Answer is B
Explanation
A.Restraints should never be applied directly on the skin or under clothing, as this can cause irritation, pressure injuries, and make it difficult for the nurse to assess skin integrity. Restraints should be placed over the client's clothing to reduce friction and protect the skin.
B.Positioning the client in a sitting or semi-Fowler's position is preferred as it promotes comfort, minimizes the risk of aspiration, and allows the nurse to monitor the client's airway, breathing, and circulation more effectively. Lying flat can increase discomfort and respiratory difficulty, especially if the client is aggressive or agitated.
C.Restraints should never be tied to movable parts, like bed rails, as this could result in injury if the bed rail is moved up or down. Restraints should be tied to a non-movable part of the bed frame to ensure stability and prevent accidental tightening or loosening that could harm the client.
D.A belt restraint should be placed across the client’s waist or hips, not the chest, as a chest restraint can impede respiratory function, especially in an aggressive client who may be physically exerting themselves. The restraint should secure the client’s lower body to prevent them from standing or moving excessively, while still allowing safe breathing and circulation.
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