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 C
Explanation
A. Encourage mobilization to prevent pulmonary embolism.
While mobilization can be important in preventing further DVT development, initial bed rest is often recommended to avoid dislodging the clot. Mobilization should be carefully managed based on the provider's recommendations.
B. Measure each calf's girth to evaluate edema in the affected leg.
Measuring calf girth is useful for monitoring the extent of the DVT, but it is not the most critical intervention compared to monitoring for complications of heparin therapy.
C. Observe for bleeding side effects related to heparin therapy.
This is the correct intervention. Heparin is an anticoagulant, and monitoring for signs of bleeding (such as in the gums, urine, stool, and bruising) is crucial to prevent serious complications.
D. Assess blood pressure and heart rate at least every 4 hours.
While important, frequent monitoring of vital signs is secondary to the need to vigilantly observe for bleeding, which is a direct and significant risk of heparin therapy.
Correct Answer is C
Explanation
A. Cover client with cooling blanket.
This could help manage the fever but is not the highest priority in the context of acute adrenal crisis.
B. Obtain an analgesic prescription.
Pain management is important, but it is not the immediate priority in a life-threatening adrenal crisis.
C. Infuse an intravenous fluid bolus.
This is the correct answer because the client is experiencing hypotension (low blood pressure), which is critical in an acute adrenal crisis. IV fluids are essential to restore blood pressure and perfusion.
D. Administer PRN oral antipyretic.
Managing the fever is important, but not the first priority. The client’s hemodynamic instability needs to be addressed immediately.
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