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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. Discuss with the client that there may be a need for additional sleep if the feeling of fatigue is present the next day. B. Encourage the client to obtain a prescription for a benzodiazepine antagonist. C. Instruct the client that it is important to reduce the dose of the medication gradually. D. Advise the client to stop taking the medication immediately.

Correct Answer is C

Explanation

Rationale:

A. While additional sleep may be helpful, it does not address the root cause of the hangover effect from temazepam.

B. A benzodiazepine antagonist is typically used in cases of overdose, not for managing next-day drowsiness.

C. Temazepam is a benzodiazepine, and sudden discontinuation can lead to withdrawal symptoms. The nurse should advise the client to taper off the medication gradually under medical supervision to prevent withdrawal symptoms and minimize the "hangover" effect.

D. Stopping the medication abruptly can lead to withdrawal symptoms and is not recommended.

A. Clamp the catheter for 30 minutes prior to irrigating. B. Slowly irrigate catheter with saline using an infusion pump. C. Use a sterile syringe to irrigate with 20 mL normal saline. D. Power flush with 60 mL to remove mucous obstructions.

Correct Answer is C

Explanation

Rationale:

A. Clamping the catheter before irrigation is not recommended as it could cause urine retention and increase the risk of infection.

B. An infusion pump is not typically used for catheter irrigation as manual control is preferred for monitoring flow and pressure.

C. Using a sterile syringe to gently irrigate the catheter with 20 mL of normal saline is the correct approach. This method helps to clear fibrin clots and sediment without applying excessive pressure, which could damage the bladder or catheter.

D. Power flushing with 60 mL could apply excessive pressure, potentially causing trauma to the bladder or urethra.

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Correct Answer is C

Explanation

Correct Answer is C

Explanation

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A client taking temazepam informs the nurse of plans to quit taking the medication due to feelings of "hungover" the next day. Which action should the nurse implement?

Correct Answer is C

Explanation

The nurse is preparing a bladder irrigation for an adult client who has a long-term indwelling urinary catheter. The urine is cloudy with fibrin clots and sediment. Which intervention should the nurse implement?

Correct Answer is C

Explanation

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While assessing placement of a nasogastric tube (NGT), the nurse aspirates cloudy green fluid into a syringe. Which intervention should the nurse implement?

An older client who is experiencing urinary incontinence is brought to the clinic with increased confusion. The nurse observes serous drainage from a laceration on the client's left arm. Which assessment is most important for the nurse to obtain?

When entering a client's room to assess vital signs, the nurse finds the client crying. After allowing the client to express feelings, which intervention should the nurse implement?

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