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.

Monitor and record the client's urinary output every day.

Provide the client with teaching regarding a cardiac diet.

Assess the client's vital signs every 4 hours when awake.

Answer and Explanation

The Correct Answer is A

Choice A: Obtain a blood pressure reading before the client gets out of bed. This is the most important intervention, as it can prevent or detect orthostatic hypotension, which is a drop in blood pressure when changing position from lying to standing. Orthostatic hypotension can cause dizziness, fainting, or falls, and it can be caused by medications, dehydration, or cardiac problems.

Choice B: Monitor and record the client's urinary output every day. This is not the most important intervention, as it does not address the client's anxiety or adjustment issues. The urinary output should be monitored for signs of fluid balance, kidney function, or infection, but it is not a priority for this client.

Choice C: Provide the client with teaching regarding a cardiac diet. This is not the most important intervention, as it does not address the client's anxiety or adjustment issues. The cardiac diet should be taught to promote heart health, lower cholesterol, and reduce sodium intake, but it is not a priority for this client.

Choice D: Assess the client's vital signs every 4 hours when awake. This is not the most important intervention, as it does not address the client's anxiety or adjustment issues. The vital signs should be assessed for signs of infection, pain, or hemodynamic instability, but they are not a priority for this client.

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

Explanation

Choice A reason: Consuming foods with saturated fats can increase the level of low-density lipoprotein (LDL) cholesterol in the blood, which can contribute to plaque formation and narrowing of the coronary arteries.

Choice B reason: Walking 30 minutes per day can help lower blood pressure, improve blood circulation, and reduce the risk of heart attack and stroke.

Choice C reason: Using a salt substitute can help lower sodium intake, which can reduce fluid retention and lower blood pressure.

Choice D reason: Keeping a food diary can help the client monitor their calorie intake, portion size, and nutritional balance.

Choice E reason: Eating more canned vegetables can increase sodium intake, which can worsen fluid retention and blood pressure. Fresh or frozen vegetables are preferable.

Choice F reason: Including oatmeal for breakfast can provide soluble fiber, which can lower LDL cholesterol and prevent plaque formation in the coronary arteries.

A. Alcohol consumption will not produce vascular changes. B. Weight management is promoted by taking daily walks for thirty minutes. C. Salt substitutes can help with maintaining a healthy diet. D. Blood pressure readings should be taken at noontime. E. Sodium intake can be regulated by limiting canned foods in the diet. F. Uncontrolled hypertension can lead to renal damage.

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

Explanation

Choice A reason: Alcohol consumption will not produce vascular changes is incorrect information. Alcohol consumption can increase blood pressure by causing vasoconstriction, fluid retention, and interference with antihypertensive medications. The nurse should advise the client to limit alcohol intake to no more than one drink per day for women and two drinks per day for men.

Choice B reason: Weight management is promoted by taking daily walks for thirty minutes is correct information. Weight management can lower blood pressure by reducing body fat, improving blood circulation, and enhancing insulin sensitivity. The nurse should advise the client to maintain a healthy weight and engage in moderate physical activity for at least 150 minutes per week.

Choice C reason: Salt substitutes can help with maintaining a healthy diet is correct information. Salt substitutes can reduce sodium intake by replacing sodium chloride with potassium chloride or other minerals. The nurse should advise the client to use salt substitutes sparingly and consult with their healthcare provider before using them if they have kidney disease or take certain medications that affect potassium levels.

Choice D reason: Blood pressure readings should be taken at noontime is incorrect information. Blood pressure readings should be taken at different times of the day, preferably in the morning and evening, to monitor fluctuations and trends. The nurse should advise the client to use a home blood pressure monitor that is accurate and calibrated and follow proper techniques for measuring blood pressure.

Choice E reason: Sodium intake can be regulated by limiting canned foods in the diet is correct information. Sodium intake can increase blood pressure by causing fluid retention and increasing vascular resistance. The nurse should advise the client to limit sodium intake to no more than 2300 mg per day and avoid processed foods that are high in sodium, such as canned foods, soups, sauces, and snacks.

Choice F reason: Uncontrolled hypertension can lead to renal damage is correct information. Uncontrolled hypertension can damage the blood vessels in the kidneys, leading to reduced kidney function and chronic kidney disease. The nurse should advise the client to follow their prescribed treatment plan and monitor their blood pressure regularly.

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Naxlex Comprehensive Predictor Exams

Text 1:The nurse is providing lifestyle change education for a client to slow the progression of coronary artery disease. Which statement(s) made by the client should the nurse recognize as needing additional education? (Select all that apply.)

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

Explanation

The nurse is educating a client about essential hypertension prevention. Which information should the nurse provide? (Select all that apply.)

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

Explanation

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