A nurse in a provider's office is caring for a client.

Nurses' Notes

3 months ago:

Client seen in provider's office for routine physical. Today:

Client reports dizziness and light-headedness upon standing. Client reports waking up at night to void.

What actions should the nurse take? Select all that apply.

Advise the client to change positions slowly.

Check the client for orthostatic hypotension. Monitor the client for dysrhythmias.

Advise the client to restrict potassium intake.

Advise the client to take the medication before bedtime.

Answer and Explanation

Correct Answer : A,B

A.   Advise the client to change positions slowly: The client's symptoms of dizziness and light- headedness upon standing suggest orthostatic hypotension, which can be managed by advising the client to change positions slowly to minimize blood pressure drops upon standing.
B.   Check the client for orthostatic hypotension. Monitor the client for dysrhythmias: The client's symptoms, along with the report of waking up at night to void, are suggestive of orthostatic hypotension, a drop in blood pressure upon standing. Checking for orthostatic hypotension and monitoring for dysrhythmias are appropriate nursing actions to assess and manage this condition.

C.   Advise the client to restrict potassium intake: Restricting potassium intake is not indicated based on the client's symptoms of dizziness and light-headedness. This action is not relevant to the situation described.
D.   Advise the client to take the medication before bedtime: There is no indication in the scenario provided that medication timing is related to the client's symptoms. This action is not relevant to addressing the client's reported symptoms.

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Correct Answer is C

Explanation

A. "You will be weighed twice a week while receiving TPN": While weight monitoring may be part of the client's overall care plan, it is not specifically related to TPN administration.
Therefore, this statement is not a priority for inclusion in the teaching.

B. "Your blood sugar will be checked once a day": Blood sugar monitoring may be necessary for clients receiving TPN, especially if they have diabetes or are at risk of hyperglycemia. However, the frequency of monitoring may vary depending on individual factors and is not universally applicable. Therefore, this statement may or may not be accurate for this client and should not be included in the teaching.
C. "You will have a central line placed to receive TPN": TPN solutions are administered through a central venous catheter to ensure adequate and safe delivery of nutrients directly into the bloodstream. Therefore, informing the client about the need for a central line is essential for TPN administration and should be included in the teaching.
D. "Your intake and output will be measured every 2 days": While monitoring intake and output is important for assessing fluid balance and renal function, the frequency of measurement may vary depending on the client's condition and institutional protocols. Therefore, this statement
may or may not be accurate for this client and should not be a priority for inclusion in the teaching.

A. "I can take my medication in the morning with my coffee." B. “I should limit my fluid intake while on this medication." C. “I may sprinkle the medication in applesauce." D. "I will need to have blood levels drawn."

Correct Answer is D

Explanation

A. Taking theophylline with coffee may increase its absorption and risk of adverse effects due to caffeine's effects on metabolism, so this statement is not appropriate.
B. Theophylline is a bronchodilator that may cause dehydration as a side effect, so limiting fluid intake is not recommended.
C. Theophylline sustained-release capsules should not be opened, crushed, or chewed, as it can alter the drug's release characteristics and increase the risk of adverse effects.

D. Monitoring blood levels of theophylline is essential to ensure therapeutic effectiveness and avoid toxicity, so the client's understanding of the need for blood level monitoring indicates comprehension of the teaching.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who has a prescription for total parenteral nutrition (TPN). Which of the following information should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is providing teaching to a client who has a new prescription for theophylline, a sustained-release capsule. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is D

Explanation

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