A nurse at an outpatient clinic receives a call from a client who reports experiencing syncope after starting a new prescription for enalapril. Which of the following instructions should the nurse give the client?

Withhold the medication if pulse rate is less than 60/min.

Increase dietary potassium.

Rise slowly from a sitting position to a standing position.

Decrease daily fluid intake.

Answer and Explanation

The Correct Answer is C

Enalapril is an ACE inhibitor used to manage hypertension and heart failure by reducing angiotensin II–mediated vasoconstriction. A common early adverse effect is orthostatic hypotension due to systemic vasodilation, especially after the first few doses. This can lead to dizziness or syncope when changing positions too quickly. Patient education focuses on safety measures that reduce sudden drops in blood pressure and prevent falls.

Rationale:
A. Withholding the medication based on pulse rate is not appropriate because enalapril does not primarily affect heart rate. It acts on the renin-angiotensin-aldosterone system to lower blood pressure, so monitoring parameters are more related to blood pressure than pulse rate. This instruction is not relevant to the reported adverse effect.

B. Increasing dietary potassium is unsafe because enalapril can increase potassium levels by decreasing aldosterone secretion. This raises the risk of hyperkalemia, which may lead to cardiac dysrhythmias. Clients taking ACE inhibitors are usually advised to avoid excessive potassium intake or potassium supplements.

C. Rising slowly from sitting or lying positions helps prevent orthostatic hypotension, a known effect of Enalapril. Gradual position changes allow the cardiovascular system to adjust and maintain cerebral perfusion, reducing the risk of dizziness and syncope. This is the most appropriate safety instruction for the client.

D. Decreasing daily fluid intake is not recommended because adequate hydration is necessary to maintain blood pressure and renal perfusion. Excessive fluid restriction could worsen hypotension and renal function. Fluid management should be individualized, but routine reduction is not an appropriate response to this medication effect.

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Correct Answer is B

Explanation

Dietary management of hypertension often includes sodium restriction, such as a 2-gram sodium diet, to help reduce fluid retention and lower blood pressure. Sodium is commonly found in processed, cured, and preserved foods, while natural whole foods tend to contain minimal amounts. Clients are encouraged to choose fresh or minimally processed options to maintain blood pressure control and reduce cardiovascular risk. Understanding food sources of hidden sodium is essential for effective dietary compliance.

Rationale:
A. Hot dogs are highly processed meats that contain significant amounts of sodium used for preservation and flavor enhancement. They are considered one of the highest sodium-containing foods and are not appropriate for a low-sodium diet. Regular consumption can contribute to fluid retention and worsening hypertension.

B. Frozen fruit is generally low in sodium, especially when it is plain and without added sauces or preservatives. In the context of a 2-gram sodium diet, frozen fruit is an appropriate choice because it is minimally processed and retains its natural nutrient profile. It is one of the safest options among the listed foods for sodium restriction.

C. Salad dressings often contain high levels of sodium, along with added preservatives and flavor enhancers. Even small servings can significantly contribute to daily sodium intake. Many commercial dressings are not suitable for clients on restricted sodium diets unless specifically labeled low-sodium.

D. Cheddar cheese contains moderate to high amounts of sodium due to its processing and aging methods. Dairy products like processed cheeses are common hidden sources of sodium in the diet. Regular consumption may interfere with sodium restriction goals in hypertensive clients.

A. Hemorrhoids on the rectal area B. Nipple tenderness with breastfeeding C. Moderate lochia rubra on the pad D. Calf edematous and tender

Correct Answer is D

Explanation

Postpartum assessment within the first 24–48 hours focuses on identifying normal recovery changes versus early complications following vaginal delivery. A key priority is detecting signs of thromboembolic events, infection, and hemorrhage in clients recovering after childbirth. One of the most serious early postpartum complications is development of a deep venous thrombosis related to venous stasis, endothelial injury, and hypercoagulability. Prompt recognition of abnormal unilateral limb findings is critical to prevent progression to pulmonary embolism.

Rationale:
A. Hemorrhoids in the rectal area are a common postpartum finding due to increased venous pressure during pregnancy and delivery. They may cause discomfort but are not considered an urgent complication. Conservative management such as sitz baths, stool softeners, and topical treatments is typically sufficient and does not require immediate escalation.

B. Nipple tenderness with breastfeeding is a common early postpartum issue as the client and newborn adjust to feeding technique. Mild discomfort is expected and often improves with correct latch and positioning. While education may be needed, this finding does not require urgent reporting.

C. Moderate lochia rubra at 24 hours postpartum is an expected normal finding as the uterus sheds decidual tissue. Lochia should be red and moderate in amount during the early postpartum period. Unless there is heavy bleeding or foul odor, this is considered within normal physiological recovery.

D. Calf edema and tenderness are concerning findings that may indicate a developing deep vein thrombosis, a serious postpartum complication. Pregnancy and the postpartum state increase clotting risk due to hypercoagulability and reduced mobility. Unilateral calf pain, swelling, and tenderness require immediate escalation to rule out Deep vein thrombosis because of the risk of embolization to the lungs.

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A nurse at an outpatient clinic receives a call from a client who reports experiencing syncope after starting a new prescription for enalapril. Which of the following instructions should the nurse give the client?

Nursing Test Bank

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