The healthcare provider has ordered an angiotensin-converting enzyme (ACE) inhibitor for the client diagnosed with congestive heart failure.
Which discharge instructions should the nurse include?
Instruct the client to take a cough suppressant if a cough develops.
Explain the importance of taking the medication with food.
Orthostatic hypotension may occur with ACE inhibitors as a result of vasodilation.
Encourage the client to eat bananas to increase potassium level.
The Correct Answer is C
Choice A rationale
A persistent, dry, nonproductive cough is a common side effect of ACE inhibitors due to the accumulation of bradykinin in the respiratory tract. However, instructing a client to take a cough suppressant is inappropriate because the cough is a pharmacological side effect that will not respond well to suppressants. If the cough becomes intolerable for the client, the healthcare provider must be notified to potentially switch the medication to an angiotensin II receptor blocker instead of masking the symptom.
Choice B rationale
Most ACE inhibitors can be taken without regard to food, though some specific ones like captopril have better absorption on an empty stomach. Telling a client to take it with food is not a universal requirement for this class of medication and is not the most critical safety instruction. The priority for discharge teaching focuses on safety and hemodynamic stability, such as managing the vascular changes that occur when the renin-angiotensin-aldosterone system is inhibited by the new medication regimen.
Choice C rationale
ACE inhibitors promote vasodilation and reduce fluid volume by blocking the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor. This reduction in peripheral vascular resistance can lead to a significant drop in blood pressure when changing positions. The nurse must instruct the client to rise slowly from a sitting or lying position to prevent falls and injury. This education is vital for safety, as orthostatic hypotension is a frequent and potentially dangerous adverse effect during initial therapy.
Choice D rationale
ACE inhibitors block the secretion of aldosterone, which normally promotes the excretion of potassium in the kidneys. By inhibiting this process, these medications can lead to hyperkalemia, where potassium levels exceed the normal range of 3.5 to 5.0 mEq/L. Encouraging the consumption of high-potassium foods like bananas increases the risk of developing cardiac arrhythmias due to dangerously high serum potassium levels. Clients should actually be cautioned against using salt substitutes or excessive potassium intake while on this medication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Pericardiocentesis is the urgent removal of fluid from the pericardial sac using a needle. The client is demonstrating Beck's triad, which includes hypotension, muffled heart sounds, and jugular venous distention, indicating cardiac tamponade. This condition occurs when fluid accumulation increases intrapericardial pressure, preventing the ventricles from filling during diastole. By draining the fluid, the nurse anticipates restoring cardiac output and preventing total cardiovascular collapse, which is the primary goal in this life-threatening obstructive shock state.
Choice B rationale
A left ventricular assist device is a mechanical pump used to support heart function and blood flow in people with weakened hearts, usually during end-stage heart failure. While it improves systemic perfusion, it is not a treatment for pericardial effusion or tamponade. Inserting such a device while the heart is compressed by external fluid would not resolve the pressure issues and would be an inappropriately invasive and ineffective response to an acute tamponade emergency.
Choice C rationale
Septal myectomy is a surgical procedure performed to remove a portion of the thickened septal wall in patients with hypertrophic obstructive cardiomyopathy. This surgery aims to relieve the outflow tract obstruction and improve blood flow from the left ventricle. It is a planned, elective procedure for chronic structural issues rather than an emergency intervention for acute pericardial effusion. It does nothing to relieve the external pressure caused by fluid buildup within the pericardial lining.
Choice D rationale
Synchronized electrical cardioversion is used to treat hemodynamically unstable tachydysrhythmias, such as atrial fibrillation or ventricular tachycardia with a pulse, by delivering a timed shock. However, the hypotension and muffled heart sounds in this scenario are caused by mechanical compression from fluid, not an electrical conduction problem. Shocking a patient in tamponade would be ineffective and potentially harmful, as it fails to address the underlying physical obstruction that is preventing ventricular filling and stroke volume.
Correct Answer is B
Explanation
Choice A rationale
Thickening of the ventricular walls and the septum is the hallmark of hypertrophic cardiomyopathy, not pericarditis. In that condition, the muscle tissue becomes abnormally thick, which can make it harder for the heart to pump blood and may lead to arrhythmias. Pericarditis does not involve the growth or thickening of the myocardium itself; it is strictly a disorder of the protective layers surrounding the heart. Explaining the condition this way would be scientifically inaccurate.
Choice B rationale
Acute pericarditis is defined as the inflammation of the pericardium, which is the thin, two-layered membranous sac that encloses the heart. This inflammation often leads to chest pain that worsens with deep breathing or lying flat and may produce a pericardial friction rub. The inflammation can be caused by infections, autoimmune disorders, or trauma. This statement correctly identifies the anatomical location and the pathological process involved, making it the most appropriate explanation for patient education.
Choice C rationale
Excessive stretching of the ventricles is associated with dilated cardiomyopathy, a condition where the heart chambers enlarge and the muscle weakens. This stretching results in a decreased ejection fraction and signs of heart failure. Pericarditis involves the external sac and does not primarily cause the heart muscle to stretch out. Using this description would confuse the patient about the nature of their diagnosis, as it describes a structural muscle failure rather than an inflammatory process.
Choice D rationale
Compression of the myocardium due to fluid accumulation describes a pericardial effusion or cardiac tamponade. While these can be complications of acute pericarditis, they are not the definition of the disease itself. Pericarditis is the inflammation of the membranes, which may or may not lead to significant fluid buildup. It is important to distinguish the primary inflammatory cause from the potential secondary effect of fluid pressure to ensure the patient understands why they have pain.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.