A nurse assesses a patient in an outpatient clinic. Which statement alerts the nurse to the possibility of left-sided heart failure?

Choice A reason: A decreased heart rate is not a typical outcome of ACE inhibitor therapy. ACE inhibitors primarily work by relaxing blood vessels, which lowers blood pressure. They do not directly affect the heart rate. While some blood pressure medications can influence heart rate, this is not a common effect of ACE inhibitors like lisinopril.

Choice B reason: A decrease in chest pain is also not a primary outcome of ACE inhibitor therapy. While lowering blood pressure can help reduce the workload on the heart and potentially decrease angina (chest pain), this is more of an indirect effect. ACE inhibitors are primarily used for hypertension and heart failure, not specifically for pain relief.

Choice C reason: Hypokalemia, or low potassium levels, is not an expected outcome of taking an ACE inhibitor. In fact, ACE inhibitors can lead to hyperkalemia (high potassium levels) because they decrease aldosterone production, which causes the body to retain potassium. Patients on ACE inhibitors are often monitored for signs of hyperkalemia rather than hypokalemia.

Choice D reason: The correct and expected outcome of taking lisinopril, an ACE inhibitor, is decreased blood pressure. ACE inhibitors prevent the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor. By reducing levels of angiotensin II, ACE inhibitors help relax blood vessels, which lowers blood pressure and makes it easier for the heart to pump blood. This is the primary therapeutic effect of the medication.

Choice A reason: Keeping the head of the bed elevated at least 30 degrees is crucial in preventing ventilator-associated pneumonia (VAP). Elevating the head of the bed reduces the risk of aspiration of gastric contents and oral secretions into the lungs, which can lead to infection. This positioning helps improve lung expansion and facilitates drainage, thereby decreasing the likelihood of VAP.

Choice B reason: Administering ordered antibiotics as scheduled is important for treating existing infections but is not a primary preventive measure for ventilator-associated pneumonia. While antibiotics play a role in managing infections, the focus here is on preventive strategies. Overreliance on antibiotics can also lead to antibiotic resistance, making infection control more challenging.

Choice C reason: Hyperoxygenating the patient before suctioning is a standard practice to prevent hypoxia during the procedure, but it is not directly related to preventing ventilator-associated pneumonia. While hyperoxygenation helps maintain adequate oxygen levels, it does not address the specific risk factors associated with the development of VAP.

Choice D reason: Suctioning the airway every 2 hours may be necessary for some patients to maintain airway patency and remove secretions. However, routine suctioning at fixed intervals is not always appropriate and can increase the risk of trauma to the airway and infection. Suctioning should be performed based on clinical assessment and the patient's needs rather than a fixed schedule to prevent complications and potential infections.