An older adult client recovering from coronary artery bypass surgery becomes weak and dizzy when standing to ambulate in the hall with the unlicensed assistive personnel (UAP). The UAP assists the client back into bed and notifies the nurse of the occurrence. Which intervention is most important for the nurse to include in the client's plan of care?

Provide client with dietary teaching regarding a cardiac diet.

Obtain client's vital signs every 4 hours when awake.

Obtain a blood pressure reading before client gets out of bed.

Measure and record the client's urinary output every day.

Answer and Explanation

The Correct Answer is C

A. Dietary teaching is important for long-term health but does not address the immediate issue of dizziness upon standing.
B. Monitoring vital signs every 4 hours is important, but obtaining blood pressure before standing is crucial to prevent falls and manage orthostatic hypotension.
C. Measuring blood pressure before the client stands helps identify orthostatic hypotension, which could be causing weakness and dizziness.
D. Measuring urinary output is relevant but not immediately pertinent to the client's dizziness and weakness on standing.

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Correct Answer is C

Explanation

A. Palpating muscle tone is important but should be done in conjunction with resistance testing to assess strength.

B. Asking the client to close his eyes is not necessary for assessing muscle strength.

C. Applying resistance while the client extends and flexes his arms helps evaluate the muscle strength and function accurately.

D. Providing an object to hold is not relevant for assessing muscle strength in this context.

A. Place the vial with the remainder of the medication into a locked drawer. B. Ask another nurse to witness the medication being discarded. C. Withdraw the medication into a syringe and label it with the client's name. D. Throw the vial into the trash in the presence of another nurse.

Correct Answer is B

Explanation

A. Storing the remainder of the medication in a locked drawer is not appropriate for controlled substances that are not fully administered.
B. Lorazepam is a controlled substance, and any unused portion must be disposed of according to hospital policy, typically by discarding it with a witness. The presence of another nurse to witness the discarding process ensures proper documentation and compliance with legal regulations.
C. Withdrawing the medication into a syringe and labeling it is unsafe as it may lead to medication errors or misuse.
D. Simply throwing the vial into the trash, even with another nurse present, does not comply with the proper disposal procedure for controlled substances.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

To assess a male client's muscle strength, the nurse first asks the client to extend his arms. Before asking the client to flex his arms, what should the nurse do?

Correct Answer is C

Explanation

The nurse is preparing to administer lorazepam 1.5 mg IV to an anxious preoperative client. The medication is available in a 2 mg/mL vial. Which action should the nurse perform with the remainder of the medication?

Correct Answer is B

Explanation

A client who is in shock is receiving a continuous IV infusion of a sympathomimetic dopamine. Which intervention should the nurse include in this client's plan of care?

A parent brings a preteen daughter to the clinic for her first female examination. During the health assessment, the nurse should implement which technique to determine if the client has reached the age of menarche?

In assessing a client's neck, the nurse hears a blowing swish when auscultating the area over the left carotid artery, but hears no sound over the right carotid artery. How should the nurse document this finding?

An older adult client with heart failure comes to the emergency room because of nausea, vomiting, and anorexia. Based on the client's signs and symptoms, which data from the medical history has the most significance when planning this client's care?

The nurse is teaching a spouse how to care for a client who recently had a stroke and has residual weakness on the right side. Which style shoes should the nurse recommend the client wear when ambulating with the spouse's assistance?

A client who is taking an oral contraceptive receives a new prescription for erythromycin. Which instruction should the nurse provide to the client?

Which client is at greatest risk for aspiration?

Which intervention is most important for the nurse to implement when administering medications?