A nurse is reinforcing teaching about delirium with the caregiver of a client. Which of the following information should the nurse include?

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.

A) "Ensure that the negative air pressure is active for the client’s room.": Negative air pressure is used for airborne precautions, such as in the case of tuberculosis or other airborne infections. MRSA is primarily spread through direct contact, not airborne transmission, so negative air pressure is not necessary in this situation.

B) "Place the client in a room with a high-efficiency particulate air (HEPA) filter.": A HEPA filter is used for airborne precautions to filter out airborne particles like those found in diseases such as tuberculosis or measles. Since MRSA is transmitted through direct contact and not airborne particles, placing the client in a room with a HEPA filter is not necessary.

C) "Have the client wear a mask when they are out of their room.": MRSA is typically spread by direct contact with infected wounds, bodily fluids, or contaminated surfaces. It is not transmitted via respiratory droplets, so there is no need for the client to wear a mask when they leave their room. The focus should be on contact precautions rather than respiratory precautions.

D) "Don gloves prior to assisting the client with brushing their teeth.": MRSA is a contact-borne infection, so it is essential to use proper personal protective equipment, such as gloves, when coming into direct contact with the client or any of their bodily fluids or contaminated items (such as toothbrushes). Donning gloves prior to assisting with brushing their teeth ensures that the nurse avoids direct contact with potential sources of infection. This is an important measure in preventing the spread of MRSA.