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."

Answer and Explanation

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.

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Correct Answer is D

Explanation

Correct. Applying ant embolic stockings while the client is still in bed helps prevent venous stasis.
Incorrect. Turning the stockings inside out is not a correct step in the application process and should be corrected by the nurse.
Correct. Asking the client to point their toes helps ensure proper positioning of the stockings.
Ensuring that creases are on the front of the legs helps prevent pressure points.

A. Assists the client to the bathroom every 2 hr B. Locks the wheels on the client's bed C. Raises all four side rails on the client's bed D. Clears furniture from the path leading to the bathroom

Correct Answer is C

Explanation

A. Assisting the client to the bathroom at regular intervals helps prevent falls due to toileting needs.

B. Locking the wheels on the bed prevents unwanted movement and reduces the risk of falls when the client is in bed.

C. Raising all four side rails is considered a restraint, which can increase the risk of falls or injury if the client tries to climb over them. Restraints should be avoided unless absolutely necessary and prescribed by a healthcare provider. In most cases, raising two side rails is sufficient to prevent the client from accidentally rolling out of bed while allowing them to safely exit the bed.

D. Clearing the path from obstacles and furniture reduces the risk of falls by providing a safe and unobstructed route to the bathroom.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is supervising an assistive personnel (AP. who is applying anti-embolic stockings for a client. Which of the following actions by the AP requires intervention by the nurse?

Correct Answer is D

Explanation

A nurse is supervising an assistive personnel (AP. who is caring for a client who is at risk for falls. For which of the following actions by the AP should the nurse intervene?

Correct Answer is C

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