An elderly patient who lives in a skilled nursing facility and who likes to walk is taking a medication that lowers blood pressure by dilating blood vessels. The best nursing action for this patient is to:
Suggest total bed rest.
Assist the patient when ambulating in the hall.
Monitor intake and output.
Instruct the resident to rise slowly when getting out of bed or a chair.
The Correct Answer is D
Choice A reason: Bed rest increases clot risk and deconditioning; vasodilators lower pressure, but mobility is beneficial unless contraindicated, making this overly restrictive.
Choice B reason: Assisting ambulation helps, but it’s less proactive; it doesn’t address orthostatic hypotension risks at initiation of movement, where falls are most likely.
Choice C reason: Monitoring intake/output tracks fluid status, not directly addressing vasodilation’s hypotensive effects during position changes, missing the primary safety concern.
Choice D reason: Rising slowly counters orthostatic hypotension from vasodilation; it allows autoregulation to stabilize pressure, reducing fall risk in an active elderly patient.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Pharmacy technicians are not authorized to administer medications. Their scope involves preparation and dispensing under supervision, ensuring safety and compliance.
Choice B reason: Safe practice standards dictate that the preparing nurse administers the medications to ensure accuracy and accountability, minimizing potential errors.
Choice C reason: Delegating to the head nurse violates medication administration protocols, as accountability rests with the nurse who prepared the medications.
Choice D reason: Allowing other licensed nurses to distribute medications increases the risk of errors due to lack of firsthand knowledge of preparation specifics.
Correct Answer is A
Explanation
Choice A reason: Right patient ensures identity verification; errors here cause harm via misadministration, as drugs affect individuals differently based on physiology and condition.
Choice B reason: Right drug prevents wrong medication errors; each drug’s pharmacokinetics targets specific issues, and mistakes disrupt therapy or cause adverse reactions.
Choice C reason: Color isn’t a standard right; it’s not a reliable identifier, as formulations vary, and clinical safety relies on name, dose, and route, not appearance.
Choice D reason: Right route ensures correct delivery (e.g., IV vs. oral); wrong routes alter bioavailability and onset, risking toxicity or inefficacy per drug design.
Choice E reason: Right time optimizes efficacy; timing aligns with drug half-life and patient needs, preventing under- or overdosing from improper administration schedules.
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