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 B

Explanation

A) "I should position the car seat's retainer clip at the level of my baby's belly button.": This statement is incorrect. The retainer clip of the car seat should be positioned at the level of the baby's armpits, not the belly button. Proper placement of the retainer clip ensures the safety harness fits securely across the baby's chest, reducing the risk of injury during a crash.

B) "I should keep my baby rear-facing in the car seat until she is 2 years old.": This statement is correct and aligns with current guidelines from organizations such as the American Academy of Pediatrics (AAP). Infants and toddlers should remain in a rear-facing car seat until they are at least 2 years old or until they reach the maximum height or weight limit allowed by the car seat manufacturer for rear-facing use. Rear-facing is the safest position for infants and provides the best protection for their developing head, neck, and spine.

C) "I should enable the airbag when my baby is in the front seat of the car.": This statement is incorrect. Infants and young children should never ride in the front seat of a car with an active airbag, as airbags can cause serious injury or death in the event of a collision. Children should always be placed in the back seat, ideally in a rear-facing car seat, to minimize risk.

D) "I should place my baby in the car seat at a 90-degree angle.": This statement is incorrect. A car seat should be installed at a slight recline to ensure that the baby's airway remains open and to prevent their head from falling forward. A 45-degree angle is typically recommended for newborns, although this can vary based on the specific car seat model and the baby's size.

A. "I should expect my periods to resume in 1 month." B. "I will have large scar on my stomach after this procedure." C. "I am thankful I am done having children." D. "I will no longer need regular gynecological examination."

Correct Answer is C

Explanation

A) "I should expect my periods to resume in 1 month.": This statement suggests a misunderstanding of the procedure. After a vaginal hysterectomy, periods will not resume because the uterus is removed. If a client expresses such expectations, it may indicate a lack of understanding about the procedure's outcomes and risks, meaning informed consent may not have been adequately given.

B) "I will have a large scar on my stomach after this procedure.": A vaginal hysterectomy is typically performed through the vaginal canal, not requiring an abdominal incision. Therefore, this statement reflects a misunderstanding of the procedure's approach, and would indicate that the client has not been fully informed about the surgical method.

C) "I am thankful I am done having children.": This statement indicates that the client has understood one of the key reasons for having a vaginal hysterectomy. The procedure typically results in the inability to conceive children, which is an important consideration for informed consent. It shows the client is aware of the consequences and is making an informed decision.

D) "I will no longer need regular gynecological examination.": This statement reflects a misunderstanding. Even after a hysterectomy, it’s important for clients to continue routine gynecological exams, as they may still need to monitor other aspects of their reproductive health, including the vagina and ovaries (if retained). It indicates that the client may not have been fully informed about post-operative care requirements.

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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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