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 ["A","E"]
Explanation
A. Consuming foods high in saturated fats can contribute to the progression of coronary artery
disease by increasing levels of LDL cholesterol, which can lead to plaque buildup in the arteries. Therefore, advising the client to consume foods with saturated fats would be counterproductive to slowing the progression of the disease.
B. Walking for 30 minutes per day is a beneficial lifestyle change that can help improve
cardiovascular health by promoting physical activity and increasing circulation. This statement does not require additional education.
C. Using a salt substitute may be advisable for individuals with coronary artery disease to reduce sodium intake and lower blood pressure. This statement does not require additional education.
D. Keeping a food diary is a helpful strategy for monitoring dietary habits and identifying areas for improvement. This statement does not require additional education.
E. Eating more canned vegetables may not be the healthiest choice as canned vegetables often contain added sodium, which can contribute to hypertension and cardiovascular disease.
Encouraging the consumption of fresh or frozen vegetables would be a better dietary recommendation.
F. Including oatmeal for breakfast is a nutritious choice that can help lower cholesterol levels and improve heart health. This statement does not require additional education.
Correct Answer is ["8"]
Explanation
To calculate the dose;
Weight= 20kg
Dose = 30mg/kg/day 8 hourly
Dose per day = 2030= 600mg
8hourly dose= 600/3= 200mg
Volume to give
125mg= 5ml
200mg = 2005/125
= 8ml
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