A nurse is making a follow-up call to a client who has a new prescription for an ACE Inhibitor to treat hypertension. The client reports lightheadedness upon standing. Which of the following statements should the nurse make?

"Sit back down for a few minutes when this occurs."

"Discontinue this medication if this occurs again."

Restrict your daily fluid intake."

"Take a daily potassium supplement."

Answer and Explanation

The Correct Answer is A

A.   Correct. Lightheadedness upon standing, also known as orthostatic hypotension, can be a common side effect of ACE inhibitors. Advising the client to sit down when experiencing lightheadedness will help prevent falls.
B.   Incorrect. Discontinuing the medication without consulting a healthcare provider is not appropriate. Lightheadedness can be managed with strategies like changing positions slowly.
C.   Incorrect. Restricting fluid intake is not necessary unless advised by a healthcare provider.
Adequate hydration is important, especially with the use of certain medications.
D.   Incorrect. While potassium supplements might be prescribed in some cases with ACE inhibitors, the primary concern in this situation is addressing orthostatic hypotension.

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Correct Answer is B

Explanation

A.Restraints should be released more frequently, typically every 2 hours, to assess circulation, skin integrity, and range of motion, and to provide an opportunity for toileting and other needs.

B.It is essential to document the specific behaviors that led to the use of restraints, as this provides a clear rationale for why the restraints were necessary. This documentation is important for legal and clinical reasons and helps ensure that restraints are used appropriately and only when absolutely necessary.

C.Clients are not required to provide written consent for the use of restraints, especially in situations where restraints are necessary to protect the client or others from immediate harm. However, the nurse must follow the facility's protocol, which usually involves obtaining a physician's order and documenting the justification for the restraint use.

D.The nurse should check the client's status more frequently, typically every 15 minutes, to ensure the client's safety and well-being while in restraints.

A. The author cites references to statements made. B. The website URL is listed as .com. C. The website was last updated 3 years ago. D. The author's names listed without credentials.

Correct Answer is A

Explanation

A. Correct. Credible medical information is typically supported by references to reputable sources or studies. Authors who cite references provide evidence that their information is based on established knowledge.
B. Incorrect. The .com URL does not necessarily indicate the credibility of the information.
Websites with .org or .gov domains may be more reliable for health information.
C. Incorrect. Websites with outdated information may not be as credible since medical knowledge and practices can change over time.
D. Incorrect. Authors listed without credentials may raise doubts about the reliability of the information. Credible sources usually provide author qualifications.

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A nurse is making a follow-up call to a client who has a new prescription for an ACE Inhibitor to treat hypertension. The client reports lightheadedness upon standing. Which of the following statements should the nurse make?

Nursing Test Bank

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