A nurse is reinforcing preoperative teaching with a client who will undergo abdominal surgery. The nurse explains that the client will wear antiembolism stockings after the procedure. When the client asks what the stockings do, which of the following responses should the nurse make?

A. "Report any incidents of swelling to your lips, tongue or face."

Angioedema is a serious side effect of lisinopril, which is an ACE inhibitor. Swelling of the lips, tongue, or face can indicate angioedema, which can be life-threatening and requires immediate medical attention.

B. "Report the development of a persistent dry cough."

A persistent dry cough is a common side effect of ACE inhibitors like lisinopril. If this occurs, the healthcare provider should be notified as an alternative medication may be needed.

C. "Your cholesterol levels should be monitored monthly while taking this medication."

Monitoring cholesterol levels is not typically necessary for clients taking lisinopril. This instruction is more relevant for medications affecting lipid levels, such as statins.

D. "Make sure your diet contains a lot of potassium-rich foods."

Lisinopril can cause hyperkalemia (high potassium levels). Therefore, it is important to avoid excessive intake of potassium-rich foods to prevent complications. Clients should be advised to monitor potassium intake rather than increase it.

E. "Monitor your blood pressure on a regular basis."

Regular monitoring of blood pressure is essential for clients taking lisinopril to ensure the medication is effectively managing their hypertension and to adjust dosages as necessary.

A. Helping the client into the shower: This task can be safely delegated to an assistive personnel (AP). The AP can help the client with activities of daily living such as showering, as long as the client is stable and does not require close monitoring.

B. Ambulating the client in the hallway: This task can also be delegated to an AP. Assisting with ambulation is within the scope of practice for an AP, provided the client is stable and there are no specific concerns that require a nurse’s assessment.

C. Measuring vital signs: While measuring vital signs is a critical task, it can be delegated to an AP. The AP can be trained to accurately measure and report vital signs. However, the nurse should review and interpret the results.

D. Removing the sternal dressing: This is the correct answer. Removing a sternal dressing after cardiac surgery is a complex task that requires a nurse’s expertise2. The nurse needs to assess the surgical site for signs of infection or complications, which is beyond the scope of practice for an AP. Therefore, this task should not be delegated and should be performed by the nurse herself