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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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","F"]
Explanation
Choice B is correct because sodium intake can be regulated by limiting canned foods in the diet. Canned foods often contain high amounts of sodium as a preservative, which can increase blood pressure and fluid retention. The nurse should advise the client to choose fresh or frozen foods instead of canned foods or rinse them before eating.
Choice C is correct because salt substitutes can help with maintaining a healthy diet by reducing sodium intake. Salt substitutes are products that contain potassium chloride or other ingredients that mimic the taste of salt but have less or no sodium. The nurse should advise the client to use salt substitutes sparingly and check with their healthcare provider before using them if they have kidney problems or take certain medications.
Choice D is correct because weight management is promoted by taking daily walks for thirty minutes. Being overweight or obese can increase blood pressure and strain the heart and blood vessels. The nurse should advise the client to lose weight or maintain a healthy weight by engaging in regular physical activity and eating a balanced diet.
Choice F is correct because uncontrolled hypertension can lead to renal damage. High blood pressure can damage the blood vessels in the kidneys and impair their function, leading to chronic kidney disease or failure. The nurse should advise the client to monitor their blood pressure regularly and take prescribed medications as directed.
Choice A is incorrect because alcohol consumption can produce vascular changes that increase blood pressure. Alcohol can cause vasodilation, which lowers blood pressure temporarily, but also stimulates the sympathetic nervous system, which raises blood pressure over time. 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 E is incorrect because blood pressure readings should not be taken at noontime. Blood pressure readings should be taken at the same time each day, preferably in the morning before breakfast or in the evening before dinner, when blood pressure is usually lower and more stable. The nurse should advise the client to avoid taking blood pressure readings when they are stressed, anxious, or have just exercised or eaten.
Correct Answer is B
Explanation
Choice A reason: Marking an outline of the "olive-shaped" mass in the right epigastric area is not a priority nursing action. The mass is caused by hypertrophy of the pyloric sphincter, which obstructs gastric emptying and causes projectile vomiting. The mass may not be palpable in all cases.
Choice C reason: Monitoring amount of intake and infant's response to feedings is important, but not the highest priority. The infant may have difficulty feeding due to nausea, vomiting, and abdominal pain.
Choice D reason: Instructing parents regarding care of the incisional area is a post-operative nursing action, not a pre-operative one. The parents will need to learn how to keep the incision clean and dry, monitor for signs of infection, and administer pain medication as prescribed.
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