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 C
Explanation
A) "It takes 2 months of scheduled use before this medication is effective.":
This statement is incorrect. Montelukast is a leukotriene receptor antagonist that works to prevent asthma symptoms and improve lung function. It typically takes a few days to a week for the medication to become effective, not 2 months. Immediate relief is not expected, but long-term benefits can be seen within a relatively short period after starting the medication.
B) "I will give this medication to my child every 2 hours if he is wheezing.":
This statement is incorrect. Montelukast is a maintenance medication that is taken on a daily basis to prevent asthma symptoms. It is not a rescue medication and should not be used every 2 hours when the child is wheezing. Rescue medications like short-acting beta-agonists (e.g., albuterol) should be used during an asthma attack or when wheezing occurs.
C) "I will give this medication to my child once daily in the evening.":
This statement is correct. Montelukast is typically taken once daily in the evening. It helps to reduce inflammation and prevent asthma symptoms, and taking it in the evening aligns with the medication's intended use for long-term control of asthma.
D) "I can stop giving my child this medication if he is taking steroids.":
This statement is incorrect. Montelukast is often used alongside steroids (inhaled corticosteroids) for managing asthma. The two medications work in different ways, and discontinuing montelukast while continuing steroids may not provide optimal asthma control. It is important to follow the healthcare provider's instructions regarding the use of both medications.
Correct Answer is C
Explanation
A) Check blood pressure for a client who is short of breath:
In a mass casualty incident, triage prioritizes addressing life-threatening conditions first. While shortness of breath may indicate a serious problem, assessing blood pressure would not be the most immediate action. The nurse should focus on airway, breathing, and circulation (the ABCs) before checking vital signs like blood pressure, as these could indicate the need for more urgent interventions.
B) Identify arterial bleeding by the presence of dark red blood:
Arterial bleeding is typically characterized by bright red blood that spurts or pulses with the heartbeat. Dark red blood is more indicative of venous bleeding. Recognizing arterial bleeding involves identifying the bright red, spurting blood, not dark red blood. It is essential to address major bleeding immediately by applying pressure or using a tourniquet as needed.
C) Open the airway of a client who has a cervical injury by using the jaw-thrust technique:
In clients with potential cervical spine injuries, the jaw-thrust technique is the recommended method to open the airway, as it does not involve tilting the head and neck, which could exacerbate a cervical injury. Ensuring the airway is patent is a priority in triage, and the jaw-thrust maneuver minimizes the risk of further injury to the spine.
D) Request the assistance of another staff member to log roll a client:
While log rolling is important for proper spinal alignment in clients with suspected spinal injuries, it is not the most urgent action during triage. In the context of a mass casualty incident, other immediate interventions, such as securing the airway and controlling bleeding, should take precedence before moving the patient unless the client’s condition requires repositioning to facilitate life-saving care.
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