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?

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

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

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

Provide the client with teaching regarding a cardiac diet.

Answer and Explanation

The Correct Answer is C

A. Obtain client's vital signs every 4 hours when awake: While monitoring vital signs is essential, it is not the most immediate concern related to the medication management and adjustment to a new environment.
B. Measure and record the client's urinary output every day: While important for monitoring fluid balance, this action is not as directly related to the client's adjustment to a new environment or immediate medication effects.
C. Obtain a blood pressure reading before the client gets out of bed: Blood pressure should be monitored before the client stands up, especially when they are on a new sedative medication, to prevent orthostatic hypotension and ensure safe transitions.
D. Provide the client with teaching regarding a cardiac diet: Teaching about a cardiac diet is important but is not as immediately relevant as ensuring the client's safety and stability with their new medications and environment.

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Correct Answer is D

Explanation

A. Reporting the incident to the university's security department is an important step but not the immediate priority. The primary focus in the emergency department is to preserve forensic evidence for legal purposes.
B. While understanding the client's personal reaction is important for providing emotional support, it does not take precedence over the immediate need to preserve evidence.
C. Listening to the client’s description of the event is part of the process, but preserving evidence is more critical. The main goal during the examination is to collect and document physical evidence rather than focusing on the details of the event.
D. Ensuring the client does not shower is crucial as it preserves physical evidence from the assault, which is essential for the investigation and legal proceedings.

Correct Answer is ["18"]

Explanation

- Determine the concentration of the heparin infusion:
- The current infusion contains 25,000 units of heparin in 500 mL of solution.
- This means the concentration is 25,000 units / 500 mL = 50 units/mL.
- Calculate the new infusion rate:
- The prescription calls for 900 units of heparin per hour.
- Using the concentration from the first step, 900 units/hour ÷ 50 units/mL = 18 mL/hour.

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Naxlex Comprehensive Predictor Exams

The nurse who working in the emergency department is obtaining evidence for a rape kit from a woman who reports that she was raped while returning to her dormitory from the university library. Which intervention is most important for the nurse to implement?

Correct Answer is D

Explanation

Correct Answer is ["18"]

Explanation

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