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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.

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 C

Explanation

Choice A: Assessing pupillary response to light hourly is not related to dopamine administration. Dopamine does not affect the pupils or the cranial nerves that control them.

Choice B: Initiating seizure precautions is not necessary for a client receiving dopamine. Dopamine does not lower the seizure threshold or cause convulsions.

Choice C: Measuring urinary output every hour is an important intervention for a client receiving dopamine. Dopamine increases blood pressure and cardiac output, which improves renal perfusion and urine production. Urinary output is an indicator of the effectiveness of dopamine therapy and renal function.

Choice D: Monitoring serum potassium frequently is not directly related to dopamine administration. Dopamine does not affect potassium levels or cause hyperkalemia or hypokalemia. However, potassium levels may be affected by other factors such as fluid balance, renal function, and medications.

A. Apply an allergy identification wrist band. B. Instruct the client to avoid medication containing milk and eggs. C. Enter allergy information in the client's electronic medical record. D. Ensure the client's selections from her dietary menu. E. Notify the dietary department of the client's egg intolerance.

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

Explanation

Choice A: Applying an allergy identification wrist band is an intervention that the nurse should implement, as this can alert other health care providers of the client's allergies and prevent adverse reactions. Therefore, this is a correct choice.

Choice B: Instructing the client to avoid medication containing milk and eggs is not an intervention that the nurse should implement, as this is not a common or relevant source of allergens for this client. This is an incorrect choice.

Choice C: Entering allergy information in the client's electronic medical record is an intervention that the nurse should implement, as this can ensure accurate and updated documentation of the client's allergies and facilitate communication among health care providers. Therefore, this is another correct choice.

Choice D: Ensuring the client's selections from her dietary menu is an intervention that the nurse should implement, as this can help avoid foods that may trigger allergic reactions or intolerance for this client. Therefore, this is another correct choice.

Choice E: Notifying the dietary department of the client's egg intolerance is an intervention that the nurse should implement, as this can help modify or substitute foods that contain eggs for this client. Therefore, this is another correct choice.

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Naxlex Comprehensive Predictor Exams

A client who is hypotensive is receiving dopamine, an adrenergic agonist, IV at the rate of 8 mcg/kg/min. Which intervention should the nurse implement while administering this medication?

Correct Answer is C

Explanation

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

Explanation

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