A nurse in a provider's office is caring for a client.
Nurses' Notes
3 months ago:
Client seen in provider's office for routine physical. Today:
Client reports dizziness and light-headedness upon standing. Client reports waking up at night to void.
What actions should the nurse take? Select all that apply.
Advise the client to change positions slowly.
Check the client for orthostatic hypotension. Monitor the client for dysrhythmias.
Advise the client to restrict potassium intake.
Advise the client to take the medication before bedtime.
Correct Answer : A,B
A. Advise the client to change positions slowly: The client's symptoms of dizziness and light- headedness upon standing suggest orthostatic hypotension, which can be managed by advising the client to change positions slowly to minimize blood pressure drops upon standing.
B. Check the client for orthostatic hypotension. Monitor the client for dysrhythmias: The client's symptoms, along with the report of waking up at night to void, are suggestive of orthostatic hypotension, a drop in blood pressure upon standing. Checking for orthostatic hypotension and monitoring for dysrhythmias are appropriate nursing actions to assess and manage this condition.
C. Advise the client to restrict potassium intake: Restricting potassium intake is not indicated based on the client's symptoms of dizziness and light-headedness. This action is not relevant to the situation described.
D. Advise the client to take the medication before bedtime: There is no indication in the scenario provided that medication timing is related to the client's symptoms. This action is not relevant to addressing the client's reported symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Epoetin alfa is not administered intranasally.
B. Epoetin alfa is not administered orally because it would be destroyed by digestive enzymes and have poor absorption.
C. Epoetin alfa is typically administered subcutaneously, as it is a recombinant human erythropoietin that stimulates red blood cell production.
D. Epoetin alfa is not administered trans dermally.
Correct Answer is D
Explanation
A. Taking theophylline with coffee may increase its absorption and risk of adverse effects due to caffeine's effects on metabolism, so this statement is not appropriate.
B. Theophylline is a bronchodilator that may cause dehydration as a side effect, so limiting fluid intake is not recommended.
C. Theophylline sustained-release capsules should not be opened, crushed, or chewed, as it can alter the drug's release characteristics and increase the risk of adverse effects.
D. Monitoring blood levels of theophylline is essential to ensure therapeutic effectiveness and avoid toxicity, so the client's understanding of the need for blood level monitoring indicates comprehension of the teaching.
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