Order: 250 mL. Normal saline bolus IV over 30 minutes

On hand: 1L normal saline bags

W/hat rate will the nurse set the pump to deliver the fluid?

Choice A reason: This statement is true. The nurse should instruct the client to avoid getting up without assistance, as hydralazine can cause orthostatic hypotension, which is a sudden drop in blood pressure when changing positions. This can lead to dizziness, fainting, or falls.

Choice B reason: This statement is false. The nurse should not tell the client that upper arm pain is common with this medication, as hydralazine does not cause this side effect. Upper arm pain may be a sign of angina, which is chest pain caused by reduced blood flow to the heart. The nurse should advise the client to report any chest or arm pain to the prescriber.

Choice C reason: This statement is false. The nurse should not tell the client to not alter the medication with birth control, as hydralazine does not have a significant interaction with hormonal contraceptives. However, the nurse should advise the client to inform the prescriber if they are pregnant or planning to conceive, as hydralazine may have some effects on the fetus.

Choice D reason: This statement is false. The nurse should not tell the client to immediately report a dry cough, as hydralazine does not cause this side effect. A dry cough is more common with angiotensin-converting enzyme (ACE) inhibitors, which are another class of antihypertensive drugs.

Choice A reason: This statement is false. Atorvastatin is not a medication that the nurse should hold, as it is used to lower cholesterol and prevent cardiovascular events. It does not have a significant effect on blood pressure, heart rate, or blood glucose.

Choice B reason: This statement is true. Captopril is a medication that the nurse should hold, as it is an angiotensin-converting enzyme (ACE) inhibitor that lowers blood pressure and prevents kidney damage. However, it can also cause hyperkalemia, which is a condition where the potassium level is too high. The client has a high potassium level, which can cause cardiac arrhythmias or muscle weakness. The nurse should hold the captopril and notify the prescriber.

Choice C reason: This statement is false. Atenolol is not a medication that the nurse should hold, as it is a beta-blocker that lowers blood pressure and heart rate. It can also prevent angina and reduce the risk of heart attack. The client has a normal heart rate and a slightly elevated blood pressure, which can be expected after surgery. The nurse should monitor the client's vital signs and administer the atenolol as ordered.

Choice D reason: This statement is false. Glipizide is not a medication that the nurse should hold, as it is an oral antidiabetic drug that lowers blood glucose by stimulating the release of insulin from the pancreas. The client has a normal blood glucose level, which can be maintained by taking the glipizide as ordered. The nurse should also encourage the client to follow a balanced diet and exercise regimen.