The nurse is giving the vasodilator medication hydralazine IV push to a client with a systolic blood pressure of 210. What nursing education would be most important to include for this client?
Immediately report a dry cough
Low heart rate is common with this medication
Do not take this medication with birth control
Do not get up without assistance
The Correct Answer is D
Choice A reason: This is incorrect because a dry cough is not a common or serious side effect of hydralazine. A dry cough is more likely to occur with angiotensin-converting enzyme (ACE) inhibitors, which are another class of antihypertensive drugs.
Choice B reason: This is incorrect because hydralazine does not cause a low heart rate. In fact, hydralazine can cause a reflex increase in heart rate as a result of lowering the blood pressure. This is why hydralazine is often given with a beta-blocker, which can slow down the heart rate.
Choice C reason: This is incorrect because hydralazine does not interact with birth control. However, the nurse should advise the client to use effective contraception while taking hydralazine, as this medication can cause fetal harm if used during pregnancy.
Choice D reason: This is correct because hydralazine can cause orthostatic hypotension, which is a sudden drop in blood pressure when changing positions. This can lead to dizziness, fainting, and falls. The nurse should instruct the client to avoid getting up too quickly and to ask for assistance if needed.
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Correct Answer is D
Explanation
Choice A reason: This choice is incorrect because fluids should not be limited to 1000 mL daily for a client taking hydrochlorothiazide. Hydrochlorothiazide is a diuretic that causes the body to lose water and salt through urine. Limiting fluids can lead to dehydration, electrolyte imbalance, and kidney damage. The client should drink enough fluids to prevent thirst and dry mouth, and follow the doctor's advice on fluid intake.
Choice B reason: This choice is incorrect because this medication is not best taken at night for a client taking hydrochlorothiazide. Hydrochlorothiazide can cause frequent urination, which can disrupt the sleep cycle and cause fatigue. The client should take this medication in the morning or at least 4 hours before bedtime to avoid nocturia (nighttime urination).
Choice C reason: This choice is incorrect because dairy products should not be avoided while on this medication for a client taking hydrochlorothiazide. Hydrochlorothiazide can lower the level of calcium in the blood, which can cause muscle weakness, cramps, and osteoporosis. Dairy products are a good source of calcium and can help prevent calcium deficiency. The client should consume adequate amounts of calcium and vitamin D, and have their blood calcium level checked regularly.
Choice D reason: This choice is correct because the client should consume high potassium foods such as bananas and oranges while on this medication. Hydrochlorothiazide can lower the level of potassium in the blood, which can cause irregular heartbeat, muscle weakness, and numbness. Potassium-rich foods can help prevent potassium deficiency and maintain normal heart and muscle function. The client should also have their blood potassium level checked regularly and avoid salt substitutes that contain potassium.
Correct Answer is C
Explanation
Choice A reason: This choice is incorrect because stomach distension and constipation are not common side effects of furosemide. They may be related to other causes, such as diet, fluid intake, or medication interactions. The nurse should assess the client's abdominal status and bowel habits and provide appropriate interventions, such as increasing fiber, fluids, or laxatives.
Choice B reason: This choice is incorrect because IV site irritation, redness, and pain are not specific side effects of furosemide. They may be caused by other factors, such as infection, infiltration, or phlebitis. The nurse should inspect the IV site and catheter and change them if needed. The nurse should also monitor the client's vital signs and blood cultures for signs of infection.
Choice C reason: This choice is correct because hearing loss or impairment is a rare but serious side effect of furosemide. It can occur due to damage to the inner ear or the auditory nerve. It may be temporary or permanent, depending on the dose and duration of furosemide therapy. The nurse should stop the infusion of furosemide and notify the provider immediately. The nurse should also assess the client's hearing and balance and provide safety measures.
Choice D reason: This choice is incorrect because frequent urination is an expected effect of furosemide. Furosemide is a diuretic that increases the excretion of water and electrolytes through the urine. It helps to reduce fluid overload and edema in clients with heart failure. The nurse should measure and record the client's intake and output and monitor the client's fluid and electrolyte status.
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