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

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is ["A","B","C","E"]

Explanation

A. It is important to add the egg allergy to the client's identification arm band to alert all healthcare providers of the allergy, ensuring the safety of the client by preventing accidental exposure.

B. Asking the client to describe her reactions can help the healthcare team understand the severity of the allergies and tailor care appropriately.

C. Entering the new allergy information into the client's electronic medical record is crucial for maintaining an up-to-date health record and ensuring that all team members are aware of the allergies.

D. Eliminating chicken from the client's menu is not necessary unless the client has specifically stated an allergy to chicken. Lactose intolerance and egg allergy do not automatically imply a chicken allergy.

E. Notifying the dietary department of the client's egg intolerance is essential to prevent the inclusion of eggs in the client's meals, which could lead to an allergic reaction.

A. Serum potassium, calcium, and phosphorus. B. Erythrocytes, hemoglobin, and hematocrit. C. Leukocytes, neutrophils, and thyroxine. D. Blood pressure, heart rate, and temperature.

Correct Answer is A

Explanation

A. Serum potassium, calcium, and phosphorus: Correct! In end-stage renal disease (ESRD), the kidneys are unable to adequately filter waste products and maintain electrolyte balance.
Monitoring serum potassium, calcium, and phosphorus levels is crucial as imbalances in these
electrolytes are common and can lead to serious complications such as cardiac arrhythmias, bone disorders, and muscle weakness.
B. Erythrocytes, hemoglobin, and hematocrit: While anemia is a common complication of ESRD, monitoring erythrocyte indices (such as erythrocyte count, hemoglobin, and hematocrit) is
important, but it is not specifically related to renal function monitoring.

C. Leukocytes, neutrophils, and thyroxine: Monitoring leukocytes and neutrophils is important for assessing immune function and detecting infections, but it is not directly related to renal
function monitoring in ESRD Thyroxine monitoring is relevant for thyroid function, which is not typically affected by ESRD.
D. Blood pressure, heart rate, and temperature: Monitoring vital signs such as blood pressure,

heart rate, and temperature is important in overall client assessment, but it does not specifically address the need for monitoring electrolyte imbalances associated with ESRD These parameters may be affected by complications of ESRD, but the primary focus in ESRD monitoring is on
renal function and electrolyte balance.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C","E"]

Explanation

Which laboratory results should the nurse closely monitor in a client who has end-stage renal disease (ESRD)?

Correct Answer is A

Explanation

A client is being urgently transported to radiology for a Computerized Tomography (CT scan) after a sudden decrease in level of consciousness. The client is orally intubated and has a left lateral chest tube to 20 cm suction. Which action is most important for the nurse to take?

Which nursing intervention is most important for the nurse to include in the plan of care for a client with alcohol withdrawal delirium?

A client with pancreatitis complains of severe epigastric pain, so the nurse administers a prescribed narcotic analgesic. Ten minutes later, the client insists on sitting up and leaning forward. Which intervention should the nurse implement?

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A client with schizophrenia reports auditory hallucinations when admitted to the hospital.What question is most important for the nurse to include in the assessment of this client?