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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: While documentation and supervisor notification are crucial, immediate action involving the health care provider ensures timely response to potential adverse effects from the medication error.
Choice B reason: Relying solely on the absence of drug allergies is insufficient and may jeopardize patient safety. Errors require immediate communication and reporting for appropriate interventions.
Choice C reason: Timely provider notification prioritizes patient safety and enables corrective measures. Completing an incident report supports institutional transparency and learning to prevent future errors.
Choice D reason: Administering additional drugs risks compounding harm. The priority is addressing the initial error and ensuring patient safety without introducing further interventions.
Correct Answer is A
Explanation
Choice A reason: Narcotics are controlled substances requiring strict accountability; two nurses—one ending and one starting the shift—verify counts to ensure accuracy and prevent diversion per regulatory standards.
Choice B reason: The head nurse and pharmacist may oversee inventory, but shift change counts involve direct caregivers for real-time accuracy, not administrative staff, ensuring immediate responsibility and oversight.
Choice C reason: Involving all nurses from both shifts is impractical and unnecessary; it dilutes accountability and increases error risk, as only two are needed to confirm the count efficiently.
Choice D reason: Pharmacy technicians lack authority over unit narcotics, and the charge nurse alone doesn’t suffice; two nurses ensure a witnessed, reliable count per hospital policy and law.
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