A nurse is contributing to the plan of care for a client who is 24 hr postoperative following an aortic valve replacement with a biologic valve. Which of the following interventions should the nurse include in the plan?

Apply a cooling blanket

Monitor daily weight

Provide opioid medications on an as needed basis

PTT levels

Answer and Explanation

The Correct Answer is B

A. A cooling blanket is not typically needed unless there is a fever or postoperative temperature dysregulation, which is not a standard intervention in this case.
B. Monitoring daily weight is essential following valve replacement to detect fluid retention or heart failure, which can indicate compromised cardiac function.
C. Opioid medications may be necessary, but they should be prescribed according to the client’s pain needs rather than a routine intervention.
D. PTT levels are usually monitored for clients on anticoagulants, but since the client has a biologic valve, anticoagulation therapy is not always required as with mechanical valves.

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Correct Answer is A

Explanation

A. Providing a consistent daily routine helps reduce confusion and anxiety in clients with dementia, aiding in their orientation and functioning.
B. Allowing the client to choose activities can lead to frustration or confusion if they are unable to remember options or make decisions, thus requiring structure.
C. Using an overhead loudspeaker may confuse the client and is not effective for communication; it is often better to provide information in person.
D. Posting a written schedule can be helpful but should be combined with a consistent routine for optimal understanding and orientation. Providing a structured environment is crucial for clients with dementia.

A. Plan to lower sodium intake to 3,000 mg each day. B. Limit alcohol consumption to 3 drinks a day when hypertensive. C. Plan to have potassium blood levels checked when taking thiazide diuretics. D. Set your goal body weight within 25% of ideal body weight.

Correct Answer is C

Explanation

A. The recommended sodium intake for individuals with hypertension is typically less than 2,300 mg per day, so a goal of 3,000 mg is too high.
B. For individuals with hypertension, it is recommended to limit alcohol consumption to 1 drink per day for women and 2 drinks per day for men, so 3 drinks is excessive.
C. Planning to have potassium blood levels checked when taking thiazide diuretics is important because these medications can lead to hypokalemia (low potassium levels), making this the correct response.
D. Setting a goal body weight within 25% of ideal body weight is not a standard recommendation; weight management should focus on achieving a healthy weight, rather than a specific percentage of ideal body weight.

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A nurse is contributing to the plan of care for a client who is 24 hr postoperative following an aortic valve replacement with a biologic valve. Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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