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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Filing a report with the facility to document the incident as a near miss medication error is essential for tracking and investigating medication errors to prevent future occurrences.
B. While contacting the prescribing provider may be necessary, the priority is to report the error internally within the facility.
C. While documenting the nurse's actions is important, it is essential to report the error through the appropriate channels within the facility.
D. While informing the client about the error is necessary, the immediate action should be to report the error internally within the facility.

A. Increased heart rate B. Excessive thirst C. Moist oral mucous membranes D. Decreased blood pressure

Correct Answer is C

Explanation

A. An increased heart rate can be a sign of dehydration and would not indicate that IV fluid replacement has been effective.
B. Excessive thirst is a symptom of dehydration and would not indicate that IV fluid replacement has been effective.
C. Moist oral mucous membranes indicate improved hydration status and are a positive response to IV fluid replacement.
D. Decreased blood pressure is a sign of dehydration and would not indicate that IV fluid replacement has been effective.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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