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 D

Explanation

A) Document the infiltration: While documentation is an important part of the nursing process, it is not the first action to take. If an infiltration is suspected, the priority is to stop the infusion immediately to prevent further harm or fluid leakage into the surrounding tissues. Once the infusion is stopped, the nurse can then document the infiltration for medical record purposes.

B) Elevate the arm: Elevating the arm can help reduce swelling, but this should not be the first step. The first priority when infiltration is suspected is to stop the infusion, as continuing it can worsen the tissue damage and swelling. After stopping the infusion, elevating the arm may be considered as part of the subsequent management of the infiltration.

C) Apply a warm compress: A warm compress may be helpful after stopping the infusion, particularly if the infiltration involves non-vesicant fluids. However, applying a warm compress is not the immediate action. The first step should be stopping the infusion to prevent any further fluid from infiltrating the tissues.

D) Stop the infusion: The most immediate and appropriate action when infiltration is noted around the IV insertion site is to stop the infusion. This prevents additional fluid from leaking into the surrounding tissues, which could cause further damage. Once the infusion is stopped, the nurse can take other steps to manage the infiltration, such as assessing the site, applying a warm compress, or notifying the healthcare provider.

A. Bran muffin B. Tomato juice C. Puffed rice cereal D. Cottage cheese

Correct Answer is A

Explanation

A) Bran muffin:
Bran is high in fiber, which is beneficial for managing constipation. Fiber helps to promote bowel movements by adding bulk to stool and improving gut motility. A bran muffin is an excellent choice for a client with constipation because it is rich in insoluble fiber, which is particularly effective in relieving constipation.

B) Tomato juice:
While tomato juice can provide some vitamins and nutrients, it is low in fiber, which is essential for managing constipation. For constipation relief, it is better to choose foods high in fiber, such as whole grains, fruits, and vegetables.

C) Puffed rice cereal:
Puffed rice cereal is low in fiber, making it an unsuitable choice for someone with constipation. Although it may provide some calories, it does not offer the beneficial fiber that can help relieve constipation.

D) Cottage cheese:
Cottage cheese is low in fiber and high in protein, but it does not contribute to bowel regularity. For constipation management, it is crucial to choose foods that are high in fiber, like fruits, vegetables, and whole grains, rather than low-fiber foods like cottage cheese.

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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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