The nurse is evaluating the blood pressure for a client with hypertension who is taking a prescribed diuretic, an angiotensin-converting enzyme (ACE) inhibitor, and an angiotensin II receptor blocker (ARB). The client's first blood pressure is 145/92 mm Hg and the second measurement obtained is 150/89 mm Hg. Which of the following actions should the nurse take first?

Choice A rationale

Hypotension is not a typical sign of fluid overload. Fluid overload often presents with hypertension due to increased circulatory volume. Monitoring blood pressure is essential, but hypotension does not reliably indicate fluid overload. This option does not align with scientific understanding of fluid overload symptoms.

Choice B rationale

Distention above the pubis area suggests urinary retention or bladder distension rather than fluid overload. While important to assess, it does not directly indicate fluid overload. This symptom is more related to mechanical issues than systemic fluid imbalance and volume overload.

Choice C rationale

Hypernatremia is not a sign of fluid overload. Fluid overload typically results in dilutional hyponatremia, where excessive fluids lower sodium levels. Monitoring sodium levels is useful, but hypernatremia would suggest dehydration or other conditions, not excess fluid volume. This choice is inconsistent with scientific knowledge.

Choice D rationale

Maintaining strict intake and output records is a fundamental approach to monitoring fluid balance. Accurate measurements of fluid intake and output help detect fluid overload early. This method directly correlates with assessing excess fluid volume in clinical practice. It is a reliable, evidence-based intervention for monitoring fluid status. .

Choice A rationale

Medications, such as phosphodiesterase type-5 inhibitors (e.g., sildenafil), are typically the next line of treatment for erectile dysfunction (ED) after lifestyle modifications fail. These agents enhance blood flow to the penile tissues during sexual stimulation by inhibiting the breakdown of cyclic guanosine monophosphate, facilitating erectile function.

Choice B rationale

Negative-pressure devices, also known as vacuum erection devices, are considered third-line treatments and are typically used in clients for whom oral medications are contraindicated or have failed. These devices work by mechanically increasing blood flow to the penis but are less effective than pharmacological interventions.

Choice C rationale

Penile injections, such as alprostadil, are invasive and used as a later option when oral medications and devices are unsuccessful or contraindicated. These injections directly relax the smooth muscle to increase penile blood flow, but they are generally not first-line treatments.

Choice D rationale

Penis transplants are experimental and not recognized as a standard treatment for erectile dysfunction. This option is far from practical or feasible and is considered unsuitable for most clients, especially given the complexity of the condition.