An older client recently transferred to a rehabilitation facility after aortic valve replacement surgery is experiencing anxiety and difficulty adjusting to the transition. The healthcare provider prescribes an antidepressant and a mild sedative for sleep. Which intervention is most important for the nurse to include in the client's plan of care?
Measure and record the client's urinary output every day.
Obtain a blood pressure reading before the client gets out of bed.
Obtain the client's vital signs every 4 hours when awake.
Provide the client with teaching regarding a cardiac diet.
The Correct Answer is B
A. Measure and record the client's urinary output every day.
While monitoring urinary output is important, it is not as directly related to the safety concerns associated with the new medications and the client's current state.
B. Obtain a blood pressure reading before the client gets out of bed.
This is the correct answer because both antidepressants and sedatives can cause orthostatic hypotension, which could lead to falls or other complications. Monitoring blood pressure before the client gets up helps to prevent these issues.
C. Obtain the client's vital signs every 4 hours when awake.
Regular vital sign monitoring is important, but specific attention to orthostatic changes is more critical in this scenario.
D. Provide the client with teaching regarding a cardiac diet.
While dietary education is important for long-term health management, it does not address the immediate risk associated with the prescribed medications and potential orthostatic hypotension.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}
Explanation
Semi Fowler's position:
- This position involves raising the head of the bed to an angle of 30 to 45 degrees. It is
commonly used to improve respiratory function and comfort in patients who are experiencing
difficulty breathing. By elevating the head and torso, this position facilitates better lung expansion, helping to improve oxygenation.
Promote lung expansion:
- In patients with respiratory issues such as pneumonia, positioning that enhances lung expansion is critical. Semi Fowler's position helps to reduce pressure on the diaphragm, allowing for more effective lung expansion and improved oxygenation. This is particularly important for a patient with decreased breath sounds and consolidation in the lungs, as it aids in alleviating respiratory distress and improving gas exchange.
Correct Answer is C
Explanation
A. Aching leg. Aching leg is not a commonly occurring problem after gastric endoscopy. It may be related to positioning during the procedure or another unrelated issue.
B. Nausea. Nausea is a potential side effect of the anesthesia or sedation used during the procedure. However, it is not as commonly occurring as a sore throat after gastric endoscopy.
C. Sore throat. Sore throat is a commonly occurring problem after gastric endoscopy due to
irritation of the throat by the endoscope. It is often caused by the insertion and manipulation of the scope during the procedure.
D. Headache. While headache can occur as a side effect of anesthesia or sedation, it is not as commonly associated with gastric endoscopy as a sore throat.
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