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 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.

A. Cause of the client's death B. Last set of the client's vital signs C. Copy of the client's advance directives D. Location of the identification tag on the client's body

Correct Answer is D

Explanation

A. Incorrect. The cause of death is an important piece of information but is typically included in the official death certificate rather than in routine postmortem documentation.
B. Incorrect. While vital signs are important during the client's care, the last set of vital signs is not usually a primary focus of postmortem documentation.
C. Incorrect. Advance directives are relevant to the client's care during life but are not typically included in postmortem documentation.
D. Correct. Documentation of the location of the identification tag on the client's body is important for accurate identification and tracking during the postmortem process.

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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

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Correct Answer is C

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Correct Answer is D

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