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An older adult client recovering from coronary artery bypass surgery becomes weak and dizzy when standing to ambulate in the hall with the unlicensed assistive personnel (UAP). The UAP assists the client back into bed and notifies the nurse of the occurrence. Which intervention is most important for the nurse to include in the client's plan of care?

Provide client with dietary teaching regarding a cardiac diet.

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

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

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

Answer and Explanation

The Correct Answer is C

Rationale:

A. Dietary teaching is important for long-term health but does not address the immediate issue of dizziness upon standing.

B. Monitoring vital signs every 4 hours is important, but obtaining blood pressure before standing is crucial to prevent falls and manage orthostatic hypotension.

C. Measuring blood pressure before the client stands helps identify orthostatic hypotension, which could be causing weakness and dizziness.

D. Measuring urinary output is relevant but not immediately pertinent to the client's dizziness and weakness on standing.

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A. An area of erythema that is painful to touch. B. Shallow open ulcer with a red pink wound bed. C. A deep pocket of infection and necrotic tissues. D. Visible subcutaneous tissue with sloughing.

Correct Answer is B

Explanation

Rationale:

A. A stage 2 pressure injury is more than just erythema; it involves partial-thickness skin loss.

B. A stage 2 pressure injury presents as a shallow open ulcer with a red or pink wound bed, indicating partial-thickness loss of dermis.

C. A deep pocket of infection and necrotic tissue describes a stage 3 or 4 pressure injury, not stage 2.

D. Visible subcutaneous tissue and sloughing are characteristics of stage 3 or 4 pressure injuries, not stage 2.

A. Administer a prescribed antianxiolytic. B. Allow the client to rest before taking the vital signs. C. Notify the client representative. D. Offer the client hot tea to promote relaxation.

Correct Answer is B

Explanation

Rationale:

A. Administering an antianxiolytic might be premature and should only be done if prescribed and necessary.

B. Allowing the client to rest before taking vital signs helps ensure that the measurements are accurate and not influenced by recent emotional distress.

C. Notifying the client representative might be relevant later, but addressing the client's immediate needs and emotional state is the priority.

D. Offering hot tea may not be appropriate in this situation and does not directly address the need for accurate vital signs.

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Correct Answer is B

Explanation

Correct Answer is B

Explanation

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During the shift change report, the nurse is told that a client has a stage 2 pressure injury. Which ulcer appearance is most likely to be observed?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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