An older client recently transferred to a rehabilitation facility after aortic valve replacement surgery is experiencing anxiety and difficulty adjusting to the transition. The healthcare provider prescribes an antidepressant and a mild sedative for sleep. Which intervention is most important for the nurse to include in the client's plan of care?
Measure and record the client's urinary output every day.
Obtain a blood pressure reading before the client gets out of bed.
Obtain the client's vital signs every 4 hours when awake.
Provide the client with teaching regarding a cardiac diet.
The Correct Answer is B
A. Measure and record the client's urinary output every day.
While monitoring urinary output is important, it is not as directly related to the safety concerns associated with the new medications and the client's current state.
B. Obtain a blood pressure reading before the client gets out of bed.
This is the correct answer because both antidepressants and sedatives can cause orthostatic hypotension, which could lead to falls or other complications. Monitoring blood pressure before the client gets up helps to prevent these issues.
C. Obtain the client's vital signs every 4 hours when awake.
Regular vital sign monitoring is important, but specific attention to orthostatic changes is more critical in this scenario.
D. Provide the client with teaching regarding a cardiac diet.
While dietary education is important for long-term health management, it does not address the immediate risk associated with the prescribed medications and potential orthostatic hypotension.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Timing with meals is inappropriate for IV antibiotics because it does not maintain consistent blood levels.
B. Spacing doses every 6 hours around the clock maintains therapeutic levels and is standard for a 4-times-daily IV antibiotic.
C. This schedule leaves a long gap overnight, risking subtherapeutic levels and decreased effectiveness.
D. Limiting doses to waking hours creates uneven intervals, which may compromise treatment efficacy.
Correct Answer is A
Explanation
A. Measure urinary output every hour. Dopamine is commonly used to improve blood pressure and renal perfusion in hypotensive clients. Monitoring urinary output is crucial because dopamine can increase renal blood flow and urine output. Hourly measurement allows for early detection of changes in renal function and urine output, enabling prompt intervention if needed.
B. Initiate seizure precautions. Seizures are not a common adverse effect of dopamine administration. Therefore, initiating seizure precautions is unnecessary in this context.
C. Assess pupillary response to light hourly. While assessing pupillary response is important in neurological assessments, it is not a priority intervention specifically related to dopamine
administration for hypotension.
D. Monitor serum potassium frequently. Dopamine administration is not directly associated with alterations in serum potassium levels. While electrolyte monitoring is important in some
situations, it is not the primary concern when administering dopamine for hypotension. Monitoring urinary output is more pertinent in this scenario.
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