A nurse is monitoring a client in a telemetry unit.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and Z parameters the nurse should monitor to assess the client's progress

Answer and Explanation

The Correct Answer is []

Rationale for correct choices:

Orthostatic hypotension: The client’s dizziness when standing, which improves with rest, is characteristic of orthostatic hypotension. This condition can occur due to vasodilation from antihypertensive therapy, such as amlodipine, or age-related cardiovascular changes. Monitoring symptoms and educating the client are essential to prevent falls and injury.
Instruct the client to avoid sudden position changes: Gradually changing positions allows the cardiovascular system to compensate for shifts in blood pressure. Slow transitions from lying to sitting to standing help reduce dizziness, lightheadedness, and the risk of falls.
Monitor for orthostatic hypotension: Assessing blood pressure and heart rate in different positions identifies significant drops in systolic or diastolic pressure. Early detection allows timely interventions, such as adjusting medications or providing fluid support, to prevent complications.
Blood pressure: Continuous monitoring tracks trends and reveals whether the antihypertensive regimen is contributing to symptomatic hypotension. It guides clinical decision-making regarding medication adjustments or additional interventions to maintain hemodynamic stability.
Heart rate: Monitoring heart rate provides insight into the body’s compensatory response to hypotension. An appropriate increase in heart rate can offset drops in blood pressure, while inadequate compensation may indicate a higher risk for dizziness, syncope, or falls.

Rationale for incorrect choices:

Pulmonary edema: The client has no shortness of breath, crackles, or edema, which are hallmark signs of pulmonary congestion. This makes pulmonary edema an unlikely cause of the current symptoms, so interventions targeting fluid overload are not indicated.
Bradycardia: The client’s heart rate is within normal limits (72–78/min) and does not reflect clinically significant bradycardia. Therefore, interventions specific to low heart rate are not needed in this scenario.
Hyperglycemia: There is no evidence of elevated blood glucose levels or symptoms such as polyuria, polydipsia, or fatigue. Monitoring for hyperglycemia is not relevant to the client’s dizziness associated with orthostatic changes.
Apply compresses to forehead: While comforting, this does not address the underlying cause of orthostatic hypotension. Symptom relief without addressing postural blood pressure changes does not prevent falls or injury.
Administer intravenous fluids: IV fluids are only indicated if hypovolemia is present. The client shows stable hydration, so administering fluids would be unnecessary and could potentially cause fluid overload.
Increased potassium intake: There is no evidence of hypokalemia contributing to the dizziness or hypotension. Potassium supplementation is not indicated in this situation.
Electrolyte levels: Monitoring electrolytes is not essential here because the client’s symptoms are primarily postural and related to antihypertensive therapy rather than an electrolyte imbalance.
Respiratory rate: The client’s respiratory rate is normal and not related to orthostatic hypotension. Therefore, focusing on this parameter does not provide actionable information for the current condition.
Blood glucose levels: There are no indications of diabetes or hyperglycemia contributing to the client’s symptoms, so monitoring blood glucose is unnecessary in this scenario.

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Fill linen bags with as much soiled linen as possible: Overfilling linen bags increases the risk of tearing, contamination, and accidental exposure to pathogens. Bags should only be filled to a safe level that can be securely tied and handled.

B. Return any fresh linen not used for a client to the linen supply area: Once linens enter a client’s room, they are considered contaminated, even if unused. Returning them to the supply area poses an infection control risk, so they should not be reused for another client.

C. Use double bagging to remove soiled linen from the client’s room: Double bagging is generally not required unless the outside of the bag is contaminated or visibly soiled. Routine use of double bags is not a recommended standard practice.

D. Tie linen bags securely at the top: Properly securing linen bags prevents the spread of microorganisms, minimizes contamination risks during transport, and maintains a safe and sanitary environment. This is the correct instruction to include when teaching safe linen handling.

A. Pour the solution onto the gauze. B. Place the bottle cap face-up on a clean surface. C. Perform hand hygiene. D. Pick up the bottle with the label facing toward the palm. E. Pour 1 to 2 mL into a receptacle. F. Remove the bottle cap.

Correct Answer is C,B,D,F,E,A

Explanation

A. Pour the solution onto the gauze: This is the final step, performed after the solution has been poured into a receptacle to control the amount and maintain sterility of the gauze.

B. Place the bottle cap face-up on a clean surface: After removing the cap, placing it face-up on a clean surface prevents contamination of the inside of the cap and the solution.

C. Perform hand hygiene: Hand hygiene is the first step to reduce the risk of introducing microorganisms and maintain a sterile environment throughout the procedure.

D. Pick up the bottle with the label facing toward the palm: Holding the bottle with the label toward the palm prevents the label from getting wet or smeared, ensuring that the solution’s identity remains visible and accurate.

E. Pour 1 to 2 mL into a receptacle: Pouring a small amount first into a separate receptacle, also called “flushing” the lip of the bottle, removes any contaminants that may be present on the bottle rim, maintaining sterility of the solution applied to the gauze.

F. Remove the bottle cap: Removing the cap is done just before pouring to maintain sterility and prevent exposure of the solution to potential contaminants on the surrounding surfaces.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

Correct Answer is C,B,D,F,E,A

Explanation

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