The nurse knows that a medication has the side effect of orthostatic hypotension. Which assessment should the nurse make before administering the medication?

Apical heart rate.

Pulse pressure.

Level of consciousness.

Blood pressure.

Answer and Explanation

The Correct Answer is D

Choice A reason: The apical heart rate is important for other assessments but does not directly assess for orthostatic hypotension.

Choice B reason: Pulse pressure is not specifically related to orthostatic hypotension assessment.

Choice C reason: Level of consciousness can be affected by orthostatic hypotension but is not the primary assessment.

Choice D reason: Blood pressure should be measured in both lying and standing positions to assess for orthostatic hypotension.

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Free Nursing Study Resources

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

Explanation

Choice A reason: Keeping the room brightly lit while providing care may help with orientation but is not a specific instruction related to stroke care.

Choice B reason: Minimizing verbal interaction with the client is not advisable. Communication is essential in assessing the client's neurological status.

Choice C reason: Monitoring for change in speech is important as speech difficulties can indicate a worsening of the stroke or other neurological issues.

Choice D reason: Avoiding dropping side rails or abruptly closing the door helps minimize unnecessary stimulation and agitation, which can be beneficial for a client experiencing a stroke.

Choice E reason: Reporting any change in level of consciousness is critical as it can indicate changes in the client's condition that require immediate medical attention.

A. Prepare the client for a prescribed computed tomography (CT) scan. B. Strain the urine for the presence of stones. C. Obtain a urine specimen for analysis. D. Administer a prescribed opioid analgesic.

Correct Answer is D

Explanation

Choice A reason: Preparing the client for a CT scan is important for diagnostic purposes but is not the immediate priority in managing severe pain.

Choice B reason: Straining the urine for stones is important for confirming the presence of renal calculi but should be done after managing the acute pain.

Choice C reason: Obtaining a urine specimen for analysis is useful for diagnosing infection or other abnormalities but is secondary to pain management.

Choice D reason: Administering a prescribed opioid analgesic is the first priority to relieve the client's severe pain and provide comfort.

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The nurse knows that a medication has the side effect of orthostatic hypotension. Which assessment should the nurse make before administering the medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted during the acute phase of a stroke. The nurse observes that the client is restless and unable to follow instructions. Which instruction(s) should the nurse provide the unlicensed assistive personnel (UAP) who is assisting with the care of the client? Select all that apply.

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

Explanation

A client with renal calculi is experiencing hematuria and reports severe flank pain. Which intervention should the nurse implement first?

Correct Answer is D

Explanation

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