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 D
Explanation
Choice A reason: Removing in the medication room risks mix-ups; tablets could be dropped or misidentified before reaching the patient, compromising the three-check safety protocol.
Choice B reason: Outside the door is premature; without the patient present, verification against the MAR is incomplete, increasing error risk before final identity confirmation.
Choice C reason: At the cart is too early; medication stays packaged until bedside to ensure the right patient, right drug match, reducing handling errors or contamination.
Choice D reason: Bedside removal allows final MAR check with patient ID; it ensures accuracy, prevents mix-ups, and aligns with safety standards for administering oral medications.
Correct Answer is C
Explanation
Choice A reason: One 5-mg tablet provides only 5 mg, far below the 15 mg ordered; this underdose fails to control hypertension effectively, risking cardiovascular complications like stroke or heart failure.
Choice B reason: Two tablets yield 10 mg, still short of 15 mg; this insufficient dose wouldn’t achieve therapeutic blood pressure reduction, leaving the patient at risk for hypertensive damage.
Choice C reason: Three 5-mg tablets equal 15 mg, matching the order precisely; this dose effectively inhibits angiotensin-converting enzyme, lowering blood pressure to a therapeutic range safely.
Choice D reason: Four tablets deliver 20 mg, exceeding the order; this overdose could cause hypotension, dizziness, or renal impairment due to excessive ACE inhibition beyond therapeutic needs.
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