The nurse is sitting at the desk watching the telemetry monitors and notes a patient's rhythm suddenly shows asystole. Which action should the nurse take first?

(A) Determine the client’s blood pressure 1 min after each position change: While it’s important to check the client’s blood pressure after each position change when assessing for orthostatic hypotension, this is not the first step. The nurse should first establish a baseline blood pressure reading with the client in a supine position.

(B) Place the client in a sitting position: Although the nurse will eventually need to check the client’s blood pressure in a sitting position, the first step is to get a baseline reading with the client in a supine position.

(C) Assist the client into a standing position: The nurse will eventually assist the client into a standing position to check for changes in blood pressure, but this is not the first step. The initial step is to get a baseline reading with the client in a supine position.

(D) Check the blood pressure with the client in a supine position: This is the most appropriate first step. When checking for orthostatic hypotension, the nurse should first check the client’s blood pressure while they are lying flat (supine). This provides a baseline reading against which subsequent readings (taken when the client is sitting and standing) can be compared. If there’s a significant drop in blood pressure upon standing, this could indicate orthostatic hypotension.

A. "Report any incidents of swelling to your lips, tongue or face."

Angioedema is a serious side effect of lisinopril, which is an ACE inhibitor. Swelling of the lips, tongue, or face can indicate angioedema, which can be life-threatening and requires immediate medical attention.

B. "Report the development of a persistent dry cough."

A persistent dry cough is a common side effect of ACE inhibitors like lisinopril. If this occurs, the healthcare provider should be notified as an alternative medication may be needed.

C. "Your cholesterol levels should be monitored monthly while taking this medication."

Monitoring cholesterol levels is not typically necessary for clients taking lisinopril. This instruction is more relevant for medications affecting lipid levels, such as statins.

D. "Make sure your diet contains a lot of potassium-rich foods."

Lisinopril can cause hyperkalemia (high potassium levels). Therefore, it is important to avoid excessive intake of potassium-rich foods to prevent complications. Clients should be advised to monitor potassium intake rather than increase it.

E. "Monitor your blood pressure on a regular basis."

Regular monitoring of blood pressure is essential for clients taking lisinopril to ensure the medication is effectively managing their hypertension and to adjust dosages as necessary.