A client is being discharged home on an ACE inhibitor and a loop diuretic. The client's most recent vital signs are: oxygen saturation of 96% on room air, heart rate of 81 beats per minute, and blood pressure of 94/59 mm Hg. Which nursing diagnosis should be prioritized when planning this client's subsequent care?
Risk for hypotension
Risk for hypoxia
Risk related to medication regimen
Risk for decreased perfusion related to dysrhythmia
The Correct Answer is A
Choice A reason: The combination of an ACE inhibitor and a loop diuretic can significantly lower blood pressure. A reading of 94/59 mm Hg indicates hypotension, which may lead to dizziness, falls, or syncope. This is the most immediate concern.
Choice B reason: Oxygen saturation is within normal limits, and there are no signs of respiratory compromise. Hypoxia is not currently a risk.
Choice C reason: While medication management is important, the most pressing issue is the physiological effect of the medications—hypotension.
Choice D reason: The heart rate is normal, and there is no evidence of dysrhythmia. Perfusion risk due to dysrhythmia is not the priority at this time.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Bronchoscopy is a diagnostic and therapeutic procedure, not a preventive intervention for atelectasis. It is used when obstruction or complications are suspected.
Choice B reason: Frequent turning and ambulation are foundational nursing interventions that promote lung expansion and reduce the risk of atelectasis. They are supported by clinical guidelines.
Choice C reason: Positive pressure ventilation may be used in critical care settings but is not standard for routine postoperative prevention unless the client is ventilated.
Choice D reason: Intermittent oxygen therapy does not directly prevent atelectasis. Oxygen may be used to treat hypoxemia but does not promote alveolar expansion.
Correct Answer is A
Explanation
Choice A reason: Clients with hyperthyroidism often experience restlessness, anxiety, and insomnia. A quiet, low-stimulation environment helps reduce sympathetic overactivity and promotes rest.
Choice B reason: While clients may experience weight loss due to increased metabolism, dietary interventions should be tailored to individual needs. High-calorie diets may be appropriate but are not the priority nursing intervention.
Choice C reason: Fluid restriction is not indicated in hyperthyroidism unless there is a comorbid condition such as heart failure. Adequate hydration is generally encouraged.
Choice D reason: Excessive activity can exacerbate symptoms such as tachycardia and fatigue. Rest and energy conservation are more appropriate during acute phases.
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