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 ["8"]
Explanation
Given:
IV solution contains 100 units of regular insulin in 100 mL of 0.9% normal saline.
The prescribed rate is 8 units/hr.
First, we find out how many units are present in 1 mL of the IV solution: 100 units / 100 mL = 1 unit / 1 mL
Now, since the prescribed rate is 8 units/hr, we need to infuse 8 mL/hr of the IV solution to deliver 8 units of insulin per hour.
So, the nurse should program the infusion pump to deliver 8 mL/hr.
Correct Answer is A
Explanation
A. Determining the client's need for pain medication is a priority to ensure comfort and manage symptoms as the client approaches end of life.
B. Updating the nurse manager on the client's status is important, but it is not the priority action in terms of direct client care.
C. Conveying the client's status to the chaplain may be part of holistic care, but the immediate physical needs of the client take precedence.
D. Documenting the impending signs of death is essential for medical records, but addressing the client's comfort needs is the priority.
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