The nurse is providing care for a client diagnosed with cardiovascular disease and hypertension who is complaining of chest pain. Which medication should the nurse administer?

Choice A reason: I should continue to read the labels of foods I select at the grocery store is not a statement that indicates a need for further clarification by the nurse. This statement shows that the client understands the importance of choosing foods that are low in sodium, fat, and calories, which can help lower blood pressure and prevent complications.

Choice B reason: Keeping my blood pressure under control reduces my risk for a heart attack is not a statement that indicates a need for further clarification by the nurse. This statement shows that the client understands the benefits of pharmacologic therapy for hypertension, which can prevent or delay the development of cardiovascular disease.

Choice C reason: When I get out of bed in the morning, I should first sit for a few minutes and then stand is not a statement that indicates a need for further clarification by the nurse. This statement shows that the client understands how to prevent or minimize orthostatic hypotension, which is a possible side effect of some anti-hypertensive medications.

Choice D reason: I will be able to stop my anti-hypertensive medication when my blood pressure is normal is a statement that indicates a need for further clarification by the nurse. This statement shows that the client has a misconception about the nature and duration of pharmacologic therapy for hypertension. The nurse should explain that hypertension is a chronic condition that requires lifelong treatment and monitoring, and that stopping the medication abruptly can cause a rebound increase in blood pressure and increase the risk of complications.

Choice A reason: Placing a pad under the buttocks is not the best intervention to help prevent skin breakdown. A pad can absorb some of the moisture and protect the bed linen, but it can also trap heat and bacteria and cause irritation and infection of the skin.

Choice B reason: This is the best intervention to help prevent skin breakdown. Checking the rectal area for soiling frequently allows the nurse to remove any fecal matter and clean the skin as soon as possible. This reduces the exposure of the skin to moisture, acidity, and enzymes that can damage the skin integrity and cause inflammation and ulceration.

Choice C reason: Washing the buttocks with strong soap and water is not the best intervention to help prevent skin breakdown. Strong soap can strip the natural oils and protective barrier of the skin and make it more vulnerable to injury and infection. The nurse should use mild soap and water or a pH-balanced cleanser and pat the skin dry gently.

Choice D reason: Placing the call bell in the client's reach is not the best intervention to help prevent skin breakdown. A mentally impaired client may not be able to use the call bell or communicate their needs effectively. The nurse should not rely on the client's ability to ask for help, but rather check on the client regularly and provide appropriate care.