An older adult client recovering from coronary artery bypass surgery becomes weak and dizzy when standing to ambulate in the hall with the unlicensed assistive personnel (UAP). The UAP assists the client back into bed and notifies the nurse of the occurrence. Which intervention is most important for the nurse to include in the client's plan of care?

Provide client with dietary teaching regarding a cardiac diet.

Obtain client's vital signs every 4 hours when awake.

Obtain a blood pressure reading before client gets out of bed.

Measure and record the client's urinary output every day.

Answer and Explanation

The Correct Answer is C

A. Dietary teaching is important for long-term health but does not address the immediate issue of dizziness upon standing.
B. Monitoring vital signs every 4 hours is important, but obtaining blood pressure before standing is crucial to prevent falls and manage orthostatic hypotension.
C. Measuring blood pressure before the client stands helps identify orthostatic hypotension, which could be causing weakness and dizziness.
D. Measuring urinary output is relevant but not immediately pertinent to the client's dizziness and weakness on standing.

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Correct Answer is B

Explanation

A. Insulin requirements generally increase as pregnancy progresses due to the growing placenta and hormones that cause insulin resistance, not fluctuate significantly.
B. Insulin requirements typically begin to increase around 18 weeks of gestation and continue to rise until approximately 36 weeks due to increased insulin resistance caused by placental hormones.
C. While insulin needs do increase, they do not typically double or quadruple during the second trimester. The increase is more gradual.
D. Insulin requirements increase during pregnancy and may decrease after delivery as the placenta is no longer present, removing the source of insulin resistance.

A. Determine if the client is taking an anticholinergic drug such as benztropine mesylate. B. This is an expected side effect of chlorpromazine which requires no further action. C. Call the healthcare provider and refuse to administer any more chlorpromazine. D. Decrease the dose of chlorpromazine and notify the healthcare provider.

Correct Answer is A

Explanation

A. Spasms of the neck and back can be symptoms of acute dystonia, a side effect of antipsychotic medications like chlorpromazine. Anticholinergic drugs such as benztropine mesylate can help manage these symptoms.
B. Spasms are not an expected side effect of chlorpromazine and require intervention rather than acceptance.
C. Refusing to administer chlorpromazine without consulting the healthcare provider may be premature; the priority is to address the symptoms.
D. Decreasing the dose and notifying the healthcare provider may be necessary, but first, it’s essential to determine if anticholinergic medication is required to address the acute symptoms.

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Naxlex Comprehensive Predictor Exams

A client who is 12 weeks pregnant has type 1 diabetes mellitus. Which instruction should the nurse provide related to insulin dosages?

Correct Answer is B

Explanation

After receiving large doses of chlorpromazine for two weeks, a client begins to develop spasms of the neck and back. Which action should the nurse take?

Correct Answer is A

Explanation

When entering a client's room to assess vital signs, the nurse finds the client crying. After allowing the client to express feelings, which intervention should the nurse implement?

An older client is admitted to the medical-surgical unit after falling and fracturing the left hip. The nurse is reviewing written preoperative instructions with the client and spouse. Which action should the nurse implement while providing these instructions?

Which client is at greatest risk for aspiration?

The home care nurse has identified the nursing problem, "risk for hopelessness" for a client who is terminally ill with a life expectancy of several days. Which instruction should the nurse provide to the client's spouse?

The nurse is preparing to administer lorazepam 1.5 mg IV to an anxious preoperative client. The medication is available in a 2 mg/mL vial. Which action should the nurse perform with the remainder of the medication?

A client has an IV solution infusing through a catheter inserted in the right antecubital area. The infusion pump is alarming and indicates an occlusion. Which action should the nurse take?

A nurse is teaching an older adult client who has diabetes mellitus about preventing the long-term complications of retinopathy and nephropathy. Which of the following instructions should the nurse include?