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

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

Provide the client with teaching regarding a cardiac diet.

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

Answer and Explanation

The Correct Answer is A

A. Obtain a blood pressure reading before the client gets out of beD This intervention is important because the client is prescribed medications that may affect blood pressure, such as antidepressants and sedatives. Monitoring blood pressure before changes in position can help prevent orthostatic hypotension and related complications.

B. Measure and record the client's urinary output every day: While monitoring urinary output is important for overall assessment, it may not be the most immediate concern given the client's recent surgery and medication regimen.

C. Provide the client with teaching regarding a cardiac diet: While education on a cardiac diet is important for cardiovascular health, addressing immediate concerns related to medication effects and post-surgical recovery takes priority.

D. Obtain the client's vital signs every 4 hours when awake: While vital sign monitoring is essential, the timing of every 4 hours may not be necessary during sleep, and obtaining blood pressure readings before changes in position is more critical to prevent adverse events.

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Correct Answer is C

Explanation

A. Measuring abdominal girth is not specific to suprapubic catheter care. While it may be relevant in certain situations, it does not directly assess the condition of the catheter or its insertion site.

B. Assessing the perineal area is important, but the primary focus for a client with a suprapubic catheter should be on the insertion site itself, as this is where complications such as infection or leakage are most likely to occur.

C. Assessing the insertion site is essential to monitor for any signs of infection, inflammation, or other complications related to the catheter. This assessment helps ensure the catheter is functioning correctly and that no adverse effects are developing.

D. Palpating the flank area is generally not a routine assessment for a client with a suprapubic catheter unless there are specific concerns about kidney function or pain in that area.

A. Determine the need for urinary catheterizations. B. Titrate Oxygen to prescribed parameters. C. Receive a postoperative client and conduct the assessment D. Evaluate and update plans of care for clients.

Correct Answer is B

Explanation

A. Determining the need for urinary catheterization is within the scope of a registered nurse (RN), as it involves assessment and clinical judgment. A practical nurse (PN) does not independently determine the need for catheterization.
B. Titrating oxygen within prescribed parameters is an appropriate task for a PN, as it involves following provider orders and monitoring the client's response while working under RN supervision.
C. Receiving a postoperative client and conducting the initial assessment requires comprehensive assessment skills, which fall within the RN's scope of practice rather than the PN's.
D. Evaluating and updating plans of care require critical thinking and clinical decision-making, which are responsibilities of the RN. The PN can contribute to care but does not independently evaluate or modify care plans.

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Naxlex Comprehensive Predictor Exams

Which assessment should the home health nurse include during a routine home visit for a client who was discharged home with a suprapubic catheter?

Correct Answer is C

Explanation

The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel Which task should the nurse assign to the PN?

Correct Answer is B

Explanation

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