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?
Obtain a blood pressure reading before the client gets out of bed.
Measure and record the client's urinary output every day.
Provide the client with teaching regarding a cardiac diet.
Obtain the client's vital signs every 4 hours when awake
The Correct Answer is A
A. Obtain a blood pressure reading before the client gets out of beD This intervention is important because the client is prescribed medications that may affect blood pressure, such as antidepressants and sedatives. Monitoring blood pressure before changes in position can help prevent orthostatic hypotension and related complications.
B. Measure and record the client's urinary output every day: While monitoring urinary output is important for overall assessment, it may not be the most immediate concern given the client's recent surgery and medication regimen.
C. Provide the client with teaching regarding a cardiac diet: While education on a cardiac diet is important for cardiovascular health, addressing immediate concerns related to medication effects and post-surgical recovery takes priority.
D. Obtain the client's vital signs every 4 hours when awake: While vital sign monitoring is essential, the timing of every 4 hours may not be necessary during sleep, and obtaining blood pressure readings before changes in position is more critical to prevent adverse events.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"E"}
Explanation
Semi-Fowler's Position:This position involves the patient being partially seated (at a 30 to 45- degree angle) which aids in lung expansion and can ease breathing in patients with respiratory distress, making it the most appropriate choice for this patient.
Lung Expansion: Semi-Fowler's position helps to promote lung expansion by reducing pressure on the diaphragm, allowing for better expansion of the lungs and easier breathing.
Correct Answer is C
Explanation
A. After straight catheterization, assessing for residual urine volume in the bladder helps determine if the bladder has emptied adequately. Palpation of the client's bladder can provide information about residual urine volume.
B. Replacing the catheter with an indwelling catheter is not indicated unless there are specific reasons for continuous drainage.
C. Allowing the bladder to empty further without assessing for residual distention may lead to incomplete bladder emptying, which can cause urinary retention and discomfort.
D. Clamping the catheter for thirty minutes is not appropriate after straight catheterization and may result in urinary retention or discomfort for the client.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.