An elderly patient who lives in a skilled nursing facility and who likes to walk is taking a medication that lowers blood pressure by dilating blood vessels. The best nursing action for this patient is to:

Suggest total bed rest.

Assist the patient when ambulating in the hall.

Monitor intake and output.

Instruct the resident to rise slowly when getting out of bed or a chair.

Answer and Explanation

The Correct Answer is D

Choice A reason: Bed rest increases clot risk and deconditioning; vasodilators lower pressure, but mobility is beneficial unless contraindicated, making this overly restrictive.

Choice B reason: Assisting ambulation helps, but it’s less proactive; it doesn’t address orthostatic hypotension risks at initiation of movement, where falls are most likely.

Choice C reason: Monitoring intake/output tracks fluid status, not directly addressing vasodilation’s hypotensive effects during position changes, missing the primary safety concern.

Choice D reason: Rising slowly counters orthostatic hypotension from vasodilation; it allows autoregulation to stabilize pressure, reducing fall risk in an active elderly patient.

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Correct Answer is C

Explanation

Choice A reason: Promising instant relief is misleading; most drugs take time, and false expectations may erode trust, reducing cooperation in a toddler’s care.

Choice B reason: Calling it candy is unethical; it risks future candy confusion with drugs, potentially leading to accidental ingestion, unsafe for a 3-year-old.

Choice C reason: Confident explanation suits a toddler’s understanding; it builds trust, reduces fear, and ensures cooperation by clearly stating purpose and process age-appropriately.

Choice D reason: Firm insistence may scare a toddler; without explanation, it lacks reassurance, potentially increasing resistance and distress during medication administration.

A. Record the drugs given during the shift before the shift ends. B. Record the drugs given by the client's pharmacy technician. C. Record the drugs immediately after administration to clients. D. Record the drugs given by any member of the client-care team.

Correct Answer is C

Explanation

Choice A reason: Recording at shift’s end risks memory errors or omissions; delayed documentation compromises accuracy and legal accountability for controlled substances and patient care.

Choice B reason: Pharmacy technicians don’t administer drugs; nurses document their own actions, ensuring responsibility and precision in the medication administration record.

Choice C reason: Immediate recording post-administration ensures accuracy, timeliness, and compliance with standards; it reflects real-time events, reducing errors in patient care documentation.

Choice D reason: Recording others’ actions is inaccurate and unethical; nurses must document only their administrations, maintaining individual accountability and patient safety.

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An elderly patient who lives in a skilled nursing facility and who likes to walk is taking a medication that lowers blood pressure by dilating blood vessels. The best nursing action for this patient is to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A hospitalized 3-year-old toddler is to receive an oral medication. For the most effective approach, the nurse should tell the child:

Correct Answer is C

Explanation

Which of these is the correct way for a nurse to document medication administration?

Correct Answer is C

Explanation

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