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.
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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Correct Answer is B
Explanation
Rationale:
A. While antibiotics can influence blood glucose, the primary reason for insulin in this context is the effect of steroids and infection on blood glucose levels.
B. Methylprednisolone, a steroid, can increase blood glucose levels, necessitating the use of insulin to manage elevated glucose levels during illness.
C. The need for insulin is related to the current hospitalization and medication effects, not necessarily a long-term change in diabetes management.
D. The ease of control is less relevant compared to the fact that steroids and infection can significantly impact blood glucose levels, necessitating insulin during hospitalization.
Correct Answer is A
Explanation
Rationale:
A. Administering insulin per sliding scale is appropriate for managing elevated blood glucose in a patient who is NPO and cannot take oral hypoglycemics like metformin.
B. Repeating the test in one hour delays necessary treatment and does not address the current hyperglycemia.
C. A continuous IV infusion of insulin is more appropriate for severe hyperglycemia or critical care situations, but obtaining a sliding scale prescription is more routine in this context.
D. Administering metformin with a sip of water could be considered if the provider orders it, but typically, oral hypoglycemics are held when a patient is NPO.