The nurse knows that a medication has the side effect of orthostatic hypotension. Which assessment should the nurse make before administering the medication?

Apical heart rate.

Pulse pressure.

Level of consciousness.

Blood pressure.

Answer and Explanation

The Correct Answer is D

Choice A reason: The apical heart rate is important for other assessments but does not directly assess for orthostatic hypotension.

Choice B reason: Pulse pressure is not specifically related to orthostatic hypotension assessment.

Choice C reason: Level of consciousness can be affected by orthostatic hypotension but is not the primary assessment.

Choice D reason: Blood pressure should be measured in both lying and standing positions to assess for orthostatic hypotension.

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Correct Answer is ["A","C","E"]

Explanation

Choice A reason: Measuring the client's vital signs before walking helps ensure the client's stability and readiness for activity.

Choice B reason: Determining the need for a gait belt is typically the responsibility of the nurse, not the UAP.

Choice C reason: Reporting dizziness or lightheadedness is important for monitoring the client's response to activity and preventing falls.

Choice D reason: Instructing the client about orthostatic hypotension is not within the scope of practice for a UAP.

Choice E reason: Assisting the client to void before walking can prevent discomfort and the need for an urgent restroom break during the activity.

A. An adult who is one day postoperative for a laparoscopic cholecystectomy. B. An older client who is one day postoperative with a colostomy for colon cancer. C. An older adult who is scheduled for foot amputation due to diabetes complications. D. An adult with alcoholism, cirrhosis, and hepatic encephalopathy.

Correct Answer is A

Explanation

Choice A reason: This client is relatively stable and the care required is within the scope of practice for a practical nurse (PN). Postoperative care for a laparoscopic cholecystectomy typically involves monitoring vital signs, pain management, and encouraging early ambulation, which the PN can perform with supervision.

Choice B reason: The older client with a colostomy for colon cancer may require more complex care and education about stoma management, which might be better suited for the RN.

Choice C reason: An older adult scheduled for foot amputation due to diabetes complications may have complex needs related to diabetes management and preoperative care, which require the RN's expertise.

Choice D reason: An adult with alcoholism, cirrhosis, and hepatic encephalopathy requires close monitoring for changes in mental status and liver function, which is more appropriate for the RN to manage.

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The nurse knows that a medication has the side effect of orthostatic hypotension. Which assessment should the nurse make before administering the medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with limited tolerance for activity needs to walk in the hallway with assistance. Which instruction(s) should the nurse give to the unlicensed assistive personnel (UAP) who is assisting with the client's care? Select all that apply.

Correct Answer is ["A","C","E"]

Explanation

Which client is best to assign to the practical nurse (PN) who is assisting the registered nurse (RN) with the care of a group of clients?

Correct Answer is A

Explanation

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