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: Showing the client isn’t a standard check; patients don’t verify MAR, and this step lacks relevance to the nurse’s triple-check safety protocol.
Choice B reason: Checking before returning ensures accuracy; the third check confirms the right drug post-administration, completing the three-point verification process safely.
Choice C reason: Calling the pharmacy is unrelated; label checks occur during administration, not external consultation, making this an irrelevant timing option.
Choice D reason: Colleague checks aren’t routine; the three checks are individual, and this step doesn’t align with standard MAR verification timing protocols.
Correct Answer is A
Explanation
Choice A reason: Blood aspiration indicates vascular entry; discarding prevents IV administration of a drug meant for another route, avoiding rapid absorption risks or contamination.
Choice B reason: Giving despite blood risks unintended IV delivery; drugs like IM injections aren’t formulated for this, potentially causing toxicity or embolism.
Choice C reason: Changing the needle doesn’t address blood-mixed medication; it remains unsafe for injection, as the dose is compromised and potentially contaminated.
Choice D reason: Omitting skips treatment unnecessarily; the issue is procedural, not the order, and restarting ensures the patient receives the intended therapy safely.
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