A nurse is making a follow-up call to client who has a new prescription for ACE inhibitor to treat hypertension. The client reports lightheadedness upon standing. Which of the following statements should the nurse make?

*Restrict your daily fluid intake."

*Take a daily potassium supplement."

*Discontinue this medication if this occurs again."

"Sit back down for a few minutes when this occurs."

Answer and Explanation

The Correct Answer is D

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.

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Correct Answer is A

Explanation

A) "I should decrease my salt intake to 2 grams per day.":
This statement is correct. For clients with hypertension, a reduced salt intake is essential in managing blood pressure. The general recommendation is to limit sodium intake to less than 2,300 milligrams per day (about 2.3 grams), with an ideal target of 1,500 milligrams per day for individuals with hypertension or those at risk. Reducing salt intake helps lower blood pressure and prevent further complications.

B) "I can have two glasses of wine with dinner.":
This statement is incorrect. While moderate alcohol consumption may not be prohibited, it is important for individuals with hypertension to limit alcohol intake. The American Heart Association recommends no more than one drink per day for women. Two glasses of wine may exceed this limit, which could contribute to an increase in blood pressure.

C) "I should exercise for 5 minutes two times per week.":
This statement is incorrect. Exercise is an important component of managing hypertension, but 5 minutes of exercise twice a week is not sufficient. The general recommendation is for adults to engage in at least 150 minutes of moderate-intensity aerobic exercise or 75 minutes of vigorous-intensity exercise per week, spread throughout the week. More frequent and longer exercise sessions are necessary to improve cardiovascular health and manage blood pressure.

D) "I will set my blood pressure goal at 130 over 84.":
This statement is incorrect. The goal for blood pressure in individuals with mild hypertension is generally lower than 130/80 mm Hg, according to current guidelines. A blood pressure of 130/84 is still considered elevated. The target should be to maintain a blood pressure below 130/80 mm Hg to reduce the risk of cardiovascular complications.

A. Document the infiltration. B. Elevate the arm. C. Apply a warm compress. D. Stop the infusion.

Correct Answer is D

Explanation

A) "Document the infiltration.": While documenting the infiltration is important for medical records, it is not the most immediate action to take. The nurse’s first priority should be to stop the infusion to prevent further complications such as tissue damage or excessive fluid accumulation around the insertion site.

B) "Elevate the arm.": Elevating the arm may help with swelling if the infiltration is mild, but it does not address the primary issue of preventing further fluid leakage. Stopping the infusion is the priority action to stop the infiltration from worsening.

C) "Apply a warm compress.": A warm compress can help with the absorption of infiltrated fluid, but it should not be applied until the infusion is stopped. If the infusion continues while a compress is applied, it could lead to further tissue damage and more discomfort for the client.

D) "Stop the infusion.": The first action should be to stop the IV infusion to prevent further infiltration. This stops the flow of fluid into the tissue, which is crucial in minimizing the risk of tissue damage and complications. After stopping the infusion, the nurse can assess the site, document the findings, and take additional actions, such as applying a warm compress or elevating the arm.

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A nurse is making a follow-up call to client who has a new prescription for ACE inhibitor to treat hypertension. The client reports lightheadedness upon standing. Which of the following statements should the nurse make?

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