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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Believes the death is punishment for bad behavior: Preschoolers, typically ages 3 to 5, often engage in magical thinking and may believe that death is a result of their own actions or bad behavior. They may see death as a punishment for something they did wrong, as they have difficulty understanding the permanence and inevitability of death. This egocentric thinking is typical for their developmental stage.
B) Recognizes the parent will never wake up: Preschoolers may not yet fully comprehend the permanence of death. They may think the deceased parent will eventually wake up or return. This belief reflects their limited understanding of death, which they may view as reversible or temporary, especially if they haven't encountered death before.
C) Understands that everyone dies eventually: Preschoolers do not generally have the cognitive ability to grasp the concept that everyone dies eventually. This understanding develops later, typically during the concrete operational stage of development (around age 7 or 8), when children begin to understand death as permanent and universal.
D) Expresses curiosity about the funeral service: While some preschoolers may express curiosity about events like a funeral, it is more likely that their curiosity would be centered on simple, tangible aspects of death (such as asking questions about where the person went or what happens to their body) rather than the ceremony itself. At this stage, children may not fully understand the cultural or symbolic meanings of a funeral service.
Correct Answer is C
Explanation
A) Report the healing status of the client's surgical site to the provider:
While this is an important aspect of the nurse’s responsibilities, it does not involve the client in decision-making. Reporting the healing status is a task that requires clinical assessment, but it doesn't allow the client to have a role in making decisions about their care or treatment options.
B) Assist the client to perform exercises and ambulate on the unit:
Assisting the client with exercises and ambulation is important for recovery, but it doesn’t directly involve the client in decision-making. The nurse is providing physical assistance, but this action is more about carrying out the care plan rather than consulting or involving the client in making decisions about their care.
C) Consult the client about options proposed by the physical therapist:
This option best involves the client in decision-making. It allows the nurse to discuss with the client the different options proposed by the physical therapist and gives the client the opportunity to make informed decisions about their own care. This approach supports patient autonomy and ensures the client is an active participant in their rehabilitation process.
D) Ask the client to rate their pain on a scale from 0 to 10 every 12 hr:
While assessing pain is important for managing the client’s comfort, it doesn’t necessarily involve the client in decision-making. The client is providing information, but the nurse is still the one determining the course of action regarding pain management based on that input. It is more about assessment than collaboration in decision-making.
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