A nurse is making a follow-up call to client who has a new prescription for ACE inhibitor to treat hypertension. The client reports lightheadedness upon standing. Which of the following statements should the nurse make?
*Restrict your daily fluid intake."
*Take a daily potassium supplement."
*Discontinue this medication if this occurs again."
"Sit back down for a few minutes when this occurs."
The Correct Answer is D
A) *Restrict your daily fluid intake: Restricting fluid intake is not recommended for a client experiencing lightheadedness upon standing, especially when taking an ACE inhibitor. In fact, maintaining adequate hydration is important to help prevent hypotension, which could be exacerbated by fluid restriction. The lightheadedness may be due to orthostatic hypotension, which is a common side effect of ACE inhibitors.
B) *Take a daily potassium supplement: ACE inhibitors can increase potassium levels in the blood, potentially leading to hyperkalemia. For most clients, taking a potassium supplement is not necessary unless specified by the healthcare provider. In fact, many clients taking ACE inhibitors need to avoid excessive potassium intake, unless directed otherwise, to prevent dangerous potassium levels.
C) *Discontinue this medication if this occurs again: The nurse should not advise the client to discontinue the medication without consulting the healthcare provider. Lightheadedness upon standing is a common side effect of ACE inhibitors due to their blood pressure-lowering effects, and the healthcare provider should be notified if this becomes problematic. The decision to change or discontinue the medication should be made by the provider.
D) "Sit back down for a few minutes when this occurs": This is the most appropriate advice. Lightheadedness upon standing can be a sign of orthostatic hypotension, which is a known side effect of ACE inhibitors. The client should be instructed to sit down and rest when they experience these symptoms. If necessary, they should stand up slowly to allow their body to adjust to changes in position, which can help alleviate the lightheadedness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) The client’s vital signs are checked every 8 hr: While vital signs are an important aspect of the client's health, this information is routine and doesn't provide new insights that would impact the overall plan of care during an interprofessional team meeting. It’s important to focus on changes in the client’s condition or specific concerns that require collaboration.
B) The client has developed difficulty ambulating: This is critical information to share during the interprofessional team meeting because it may require input from physical therapists, occupational therapists, or other specialists. Difficulty ambulating can indicate a need for reassessment of the client's mobility plan, and other team members need to be informed to develop appropriate interventions.
C) The client has state-sponsored health insurance: While the client’s insurance status is relevant for financial and discharge planning, it is not directly related to the clinical management or care coordination that would be discussed in an interprofessional team meeting. The focus should be on the client’s clinical condition and needs.
D) The client's next dressing change is scheduled in 4 hr: Although the dressing change is important for continuity of care, this is more of a task-related detail rather than critical clinical information that requires interprofessional discussion. The focus in a team meeting should be on the client's progress, challenges, and needs, not just routine care tasks.
Correct Answer is B
Explanation
A) Rigid abdomen: A rigid abdomen is more commonly associated with conditions like placental abruption or uterine rupture, where there is significant internal bleeding and trauma to the uterine wall. It is not a typical finding in placenta previa, where bleeding is typically present without uterine rigidity.
B) Bright red vaginal bleeding: Bright red vaginal bleeding is the most characteristic finding in placenta previa. The condition occurs when the placenta is abnormally located in the lower part of the uterus, covering or being near the cervix. This leads to painless, bright red vaginal bleeding, which is often seen in the second or third trimester. The bleeding results from the placenta's location as the uterus expands.
C) Persistent uterine contractions: Persistent uterine contractions are more often associated with preterm labor or placental abruption, not placenta previa. While contractions can occur in placenta previa, they are not the primary or most expected symptom. The hallmark of placenta previa is bleeding, rather than contractions.
D) Increased fetal movement: Fetal movement is not typically altered by placenta previa. In some cases, the location of the placenta may affect the feeling of fetal movement, especially if the placenta is anterior, but increased fetal movement is not a specific finding associated with placenta previa. The focus should be on bleeding and uterine stability.
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