The nurse is preparing the client for discharge.

Exhibits

Which of the following statements indicate the client understands the discharge teaching?

Select the 3 client statements that indicate an understanding of the teaching.

A. Decrease daily fluid intake. Enalapril, an angiotensin-converting enzyme (ACE) inhibitor, can cause hypotension, particularly after the first dose. Decreasing fluid intake could exacerbate hypotension and increase the risk of syncope. Clients should maintain adequate hydration unless otherwise instructed by their provider.
B. Rise slowly from a sitting position to a standing position. Enalapril can cause orthostatic hypotension, especially when starting therapy. Clients should be advised to change positions slowly to reduce dizziness and syncope risk. Lying down if dizziness occurs can help restore blood pressure and prevent falls.
C. Withhold the medication if pulse rate is less than 60/min. Enalapril primarily affects blood pressure rather than heart rate. Unlike beta-blockers or some calcium channel blockers, it does not significantly lower the heart rate. The decision to hold enalapril should be based on blood pressure readings rather than pulse rate.
D. Increase dietary potassium. ACE inhibitors reduce potassium excretion, increasing the risk of hyperkalemia. Clients should be cautious with potassium-rich foods and supplements to avoid dangerous elevations in potassium levels, which can lead to cardiac complications.

A. "An incident report has been completed and sent to risk management." Incident reports are used for internal facility documentation and quality improvement but should not be mentioned in the medical record. Including this information could make the report discoverable in legal proceedings, which is why it should remain separate from the client’s medical documentation.
B. "The client fell because the assistive personnel did not place nonskid slippers on the client." This statement assigns blame without objective evidence and does not follow factual documentation principles. Medical records should include observable data, client statements, and assessments rather than subjective conclusions or assumptions about the cause of the fall.
C. "Client stated, 'I lost my balance and fell when I got out of bed to go to the bathroom.'" Including the client's direct statement ensures accurate, objective documentation. It provides firsthand information about the incident without making assumptions or assigning blame. Client statements should always be documented using quotation marks to maintain accuracy.
D. "The client does not appear to have any injuries resulting from the fall." This statement is subjective and may be misleading. A client could have internal injuries that are not immediately visible. Instead, the nurse should document a detailed physical assessment, such as "No visible injuries noted. Client denies pain or discomfort at this time."